
Book O 5 

Copyright^ i y J/ ^ 



COPYRIGHT DEPOSIT. 



New 
Clinical Therapeutics 

A Handbook on the Special Treatment 
of Internal Disease 



BY 

ALFRED C. CROFTAN, Ph.D., M. D. 

Member of the General Staff of the Michael Reese Hospital, Chicago. Formerly Physician-in-Chief at 
St. Mary's Hospital; Physician to St. Elizabeth's Hospital; Physician to the Chicago Post- 
Graduate Hospital; Pathologist to St. Luke's Hospital. Late Professor of Medicine 
at the Chicago Post- Graduate College and the Chicago Polyclinic; As- 
sistant Professor of Clinical Medicine, College of Physicians 
and Surgeons (University of Illinois); Member 
of The American Therapeutic Society. 
Author of "Clinical Urinology." 



Fourth Edition, Enlarged and Completely Revised 



1 'Nihil temere affirmandum nihil coyitemnendum." 

(Hippocrates.) 
"Medicine is an Art that sometimes cures, often 
relieves and always comforts.' " 

(F. Berard.) 



CHICAGO 
(filmland -press 

1912 



A 



N V 



Copyright 1912 

BY THE 

CLEVELAND PRESS 

CHICAGO 



GLA303742 
- NO. 1 



Dedicated to 
Elizabeth Hubbard Croftan. 



"The observation which does not teach the art of healing is 
not that of a physician; it is that of a naturalist." (Broussais.) 



"La therapeutique est la seule raison d'etre de la medicine qui, 
sans son secours, ne serait guere qu'une meditation sur la mort." 
(Roger.) 



"Die Zeiten des Nihilismus in der Klinik und des Pessimismus 
in der Praxis sind iiberwunden, sie liegen hinter uns." 



"Die innere Klinik steht heute unter dem Zeichen der Thera- 
pie." (v. Leyden.) 



"II importe de rendre a la therapeutique sa dignite, de ne plus 
la confondre avec la matiere medical, et de remettre en honneur la 
science des indications." (Bouchard.) 



"The doctrinaire in medicine, as in politics or other matters, is 
commonly a dangerous person." (Duckworth.) 



PREFACE TO FIRST EDITION. 



This book deals alone with the treatment of the sick. Hence 
the homely ministrations at the bed-side (that mean so much to 
the patient), the feeding and the bathing, the technique of all 
mechanical and physical means of treatment, as well as the use of 
medicines, the choice of climate and resorts, and the indications 
for surgical intervention are all discussed. 

As a profession we have erred in the past in giving too much 
medicine ; we err nowadays possibly in giving too little. With the 
development of modern pharmacology and the decline of crude em- 
piricism; with the tendency to give a single drug to meet definite 
indications; with the revival of esthetic medication and the aban- 
donment of nauseous polypharmacy, drugs are recovering their le- 
gitimate place in the therapeutic armamentarium even of the most 
skeptically inclined. In the meantime physical means of treat- 
ment, such as hydrotherapy, electrotherapy, massage ? the great prin- 
ciples of rest and exercise, all based upon accurate scientific obser- 
vation, have won the position they deserve. Modern dietetics, 
founded on the newly-discovered laws of nutrition and metabolism, 
has become an exact, almost mathematical, procedure. Psycho- 
therapy has been allotted a definite field of usefulness. Organo- 
therapy and, above all, serumtherapy, promise much and encourage 
the hope that our small list of specific remedies will shortly be in- 
creased. 

No attempt has been made to enumerate all the means and 
remedies that have at different times been recommended for the 
treatment of various diseases, for these belong to the historical 
rather than the immediately practical. 

It is well to recognize our limitations in the field of treatment ; 
hence rather than fill pages with a futile confession of our inability 
to help, a discussion of those disorders that we at present are un- 
able to influence by any treatment has been altogether omitted. 
For this reason no special Section on Diseases of the Nervous Sys- 
tem has been arranged; for unforhmately the majority of the or- 
ganic diseases of the nervous system, on account of the peculiar 
character of the lesions and the nature of the affected parts, are 
not amenable to internal treatment, and the functional disorders 
of the nervous system are, as a rule, successfully treated only in 
special institutions. The management of the latter class of cases 



X PREFACE. 

is discussed in the text under various headings and can be found 
by consulting the index. 

Occasionally an independent classification and grouping of re- 
lated clinical entities has been attempted, in which I have con- 
sidered it necessary from the therapeutic standpoint to depart from 
orthodox anatomic and etiologic classifications. Wherever it was 
considered essential to a better understanding of therapeutic indi- 
cations, I have prefaced the statement of the treatment by general 
remarks relating to etiology and symptomatology. 

The author of a work on Therapeutics is of necessity forced to 
draw largely from personal experience^ modified, to some extent, by 
the opinions prevailing among established authorities. This atti- 
tude naturally gives the discussion a subjective flavor, so to speak, 
which does not appear to me to be undesirable, and, which, above 
all, can hardly be avoided in a book of this character. 

In preparing certain chapters I have been so fortunate as to 
secure the co-operation of clinicians who enjoy exceptional oppor- 
tunities for observing the diseases they have written on. Thus Dr. 
Heman Spalding, as chief medical inspector of Chicago, has had a 
broad experience with the subject of Small Pox; Dr. William H. 
Baum, as physician-in-charge of the contagious wards in the Cook 
County Hospital, has had unusual opportunities for studying Scar- 
let Fever and Measles. Dr. A. Mayer and Dr. U. Maes, of New 
Orleans, have written on Yellow Fever. Dr. Wm. A. Pusey has 
contributed paragraphs on the X-ray treatment of Leukemia and 
Pseudo-leukemia ; Dr. E. F. Wells has written the Section on Pneu- 
monia; Dr. F. S. Churchill on Mumps and Whooping Cough; Dr. 
F. Kreissl, the Section on Syphilis and Cystitis and Urethritis and 
the paragraphs on intra-pelvic applications in the treatment of 
Pyelitis. To all these gentlemen I wish to express my sincere 
thanks for their earnest and valuable assistance. 

In order to render this volume useful not only for consecutive 
reading, but also for rapid reference, marginal headings have been 
inserted throughout and particular care has been expended upon the 
preparation of a complete and exhaustive index. 

Alfred C. Croftan. 



PREFACE TO SECOND EDITION. 



Within the short period of a few months that has elapsed since 
the issuance of the first double edition no fundamental advances 
in clinical therapeutics have been made. A number of promising 
ideas have been advanced by different clinicians, but it is altogether 
too early to pass judgment on their validity ; for the present, there- 
fore, I have preferred to omit them from the new text. Numerous 
suggestions, however, and a few criticisms that have been offered 
by readers of the first edition have^ whenever feasible, been duly 
considered and incorporated in the volume. To all those who have 
been so kind as to aid me in this way I wish to express my sincere 
appreciation. Alfred C. Croftan". 



PREFACE TO THIRD EDITION. 



There has been little real advance in the therapeutics of internal 
disease within the last two years. Our main hope must lie in the 
field of specific remedies; here the use of Flexner^s serum in epi- 
demic cerebro-spinal meningitis has fully vindicated its claim to 
usefulness; all other endeavors in the direction of preparing specific 
sera have so far led to no conclusive results. Consequently there is 
little that is fundamentally new to add to this Third Edition. 

Alfred C. Croftan. 



PREFACE TO FOURTH EDITION. 



This fourth edition includes all that is new and therapeutically 
practical in the field of specific prophylaxis, serum therapy, auto- 
genous vaccination and. the newer chemo-therapy. Hence the 
Chapter on Infectious Diseases principally has been enlarged. 

Many of the newer synthetic remedies that have vindicated their 
claims to usefulness have been included in the text. A new Chap- 
ter on the Commoner Intoxications has been added and each chapter 
has been revised and amplified to correspond to the progress made 
in Therapeutics since the appearance of the last (third) edition. 
This implies the addition of over 100 pages to the text. 

The Index has been enlarged by many items and a Clinical 
Index prepared for more ready orientation. I am much indebted 
to Miss S. S. Phelps for this labor. 

Alfred C. Croftan. 



TABLE OF CONTENTS. 



CHAPTER I. 



Infectious Diseases Page 17 

Prophylactic Injections. — The Treatment of Fever. Ty- 
phoid Fever. Pneumonia. Diphtheria. Malaria. 
Acute Articular Rheumatism. Dysentery. Influenza. 
Pertussis. Parotitis. Scarlet Fever. Smallpox. — 
Vaccination. — The Incubative Stage. — The Stage of 
Invasion. — The Eruptive Stage. — The Stage of Desic- 
cation. Yellow Fever. Hydrophobia. Cholera. 
Plague. Streptococcus Infections. Staphylococcus. 
Anthrax. Colon Bacillus. Epidemic Cerebro-Spinal 
Meningitis. Pulmonary Tuberculosis. Syphilis. 

CHAPTER. II. 

Diseases of the Blood Page 151 

The Anemias. Progressive Pernicious Anemia. Spinal 
Anemia. Chlorosis. Leukemia. Pseudo-Leukemia. 
The Hemorrhagic Diathesis. Scurvy. Hemophilia. 
Purpura. 

CHAPTER III. 

Diseases of Metabolism Page 187 

The Laws of Nutrition. Diabetes Mellitus. — Dietetics of 
Diabetes of Medium Severity. — Dietetics of the Severe 
Type of Diabetes. — Medicamentous Treatment of Dia- 
betes. — Exercise in Diabetes, — Treatment of the Com- 
plications and Sequelae of Diabetes. — Prophylactic and 
Causal Treatment in Diabetes. Obesity. — The Dietetic 
Treatment of Obesity. — The Science of Reduction 
Cures. — The Art of Reduction Cures. — Rheumatism. — 
Muscular Rheumatism. Chronic Rheumatism and 



XIV TABLE OF CONTENTS 

Bheumatoid Arthritis. Gout and Uric Acid Diathesis. 
Eetrocedent Gout — The Acute Attack of Gout. Osteo- 
malacia. Diabetes Insipidus. 

CHAPTEE IV. 

Diseases of the Circulatory Apparatus Page 273 

The Heart and its Membranes. Valvular Diseases of the 
Heart. — Treatment of Compensated Valvular Lesions 
of the Heart. — The Treatment of Valvular Diseases of 
the Heart with Failing or Broken Compensation. — 
Symptomatic Treatment of Stasis in Different Organs 
due to Decompensated Valvular Lesions. Treatment of 
Cardiac Dropsy and Edema. Myocarditis and Fatty 
Degeneration of the Heart. Acute Endocarditis. Peri- 
carditis. The Arteries. Arterio-sclerosis and Chronic 
Aortitis. Aneurism of the Aorta. Neuroses of the 
Heart. Angina Pectoris. Palpitation. Arrhythmia. 

CHAPTER V. 

Diseases of the Ductless Glands Page 327 

Organotherapy: Historical Eeview and Critique. Dis- 
eases of the Thyroid Gland — M}^xedema and Cretinism. 
Exophthalmic Goitre. Simple Goitre. Addison's Dis- 
ease. 

CHAPTEE VI. 

Diseases of the Urinary Apparatus Page 343 

Nephritis, Acute Nephritis, Chronic Nephritis and 
Bright's Disease. Pyonephrosis and Pyelitis. — The 
Treatment of Pyelitis by lavage of the Eenal Pelvis. 
Nephrolithiasis. Nephrolithiasis Urica. Nephrolith- 
iasis Oxalurica. Nephrolithiasis Phosphatica. Float- 
ing Kidney. Uremia. Diseases of the Bladder and 
Urethra. Cystitis. Acute Urethritis. Gonorrheal 
Urethritis. Prostatitis. Epididymitis. Cowperitis. 
Infection of the Para and Periurethral Ducts. Sper- 
matocystitis. Bartholinitis. Gonorrheal Vulvovagin- 
itis. Infectious Urethritis of Non- Gonorrheal Origin. 



TABLE OF CONTENTS XV 

CHAPTER VII. 

Diseases of the Mouth and Upper Air Passages Page 431 

Diseases of the Buccal Cavity. Stomatitis. Gingivitis. 
Tonsillitis. Diseases of the Nose and Throat. Acute 
Rhinitis and Pharyngitis — Treatment of the Acute At- 
tack. Coryza Vasomotoria and Hay Fever. Epistaxis. 
Acute Laryngitis. 

CHAPTER VIII. 

Diseases of the Bronchi Page 453 

Acute Tracheo-Bronchitis. Chronic Bronchitis and Bron- 
chiectasis. Bronchiectasis. Bronchial Asthma. Cap- 
illary Bronchitis. Broncho-Pneumonia. 

CHAPTER IX. 

Diseases of the Lungs and Pleura Page 471 

Pulmonary Emphysema. Pulmonary Edema. Pulmon- 
ary Infarct, Abscess and Gangrene. Hemoptysis. 

CHAPTER X. 

Diseases of the Digestive Apparatus Page 499 

The Stomach. Acute Gastritis. Chronic Gastritis — The 
Use and Abuse of Hydrochloric Acid — Drugs in Chronic 
Gastritis — The Use of Digestive Ferments. Gastric Ul- 
cer. Carcinoma of Stomach. Motor Insufficiency of 
the Stomach. (Gastric Dilatation, Gastric Ecstasy, 
Gastric Atony.) Gastric Hypersecretion and Hyper- 
chlorhydria. Gastric Hypersecretion and Achylia Gas- 
trica. Gastric Neurosis. Motor Neurosis. Secretory 
Neurosis. Sensory Neurosis. 

CHAPTER XL 

Diseases of the Intestine and Peritoneum Page 573 

Acute Intestinal Catarrh. Chronic Intestinal Catarrh. 

Intestinal Stenosis and Occlusion. Intestinal Ulcer. 

- Membranous Enteritis and Mucous Colic. Chronic 



XVI TABLE OF CONTENTS 

Constipation. Diarrhea. Flatulency (Meteorism). 
Intestinal Parasites. Hookworm Disease ( Ankylos- 
tomiasis, Uncinariasis). The Peritoneum. Acute Dif- 
fuse Peritonitis. Acute Circumscribed Peritonitis, 
Perityphlitis, Appendicitis. 

CHAPTEK XII. 

Diseases of the Liver and Bile Passages Page 649 

Catarrhal Jaundice. Chronic Inflammation of the Liver. 
Cholelithiasis — Treatment of the Acute Attack. Cho- 
langitis and Cholecystitis. 

CHAPTER XIII. 

The Commoner Intoxications Page 671 

Aconite. Alcohol. Alum, zimmonia. Amyl Nitrite. 
Antimony. Antipyrin. Arsenic. Atropine. Barium. 
Bee Stings. Belladonna. Botulism. Bromide. Bro- 
min. Bromoform. Calcium. Carbolic Acid. Carbon 
Dioxide. Carbon Monoxide. Cheese Poisoning. Chlo- 
ral Hydrate. Chlorate of Potash. Chlorin. Chloro- 
form. Cocaine. Colchicin. Corrosive Sublimate. Dig- 
italis. Ergot. Ether. Fish. Food. Heat Prostra- 
tion. Hydrochloric Acid. Hydrocyanic Acid. Hyo- 
cyamin. Illuminating Gas. Iodides. Iodine. Iodo- 
form. Lead. Lime Salts. Mercury. Morphine. 
Mushrooms. Nitroglycerin. Nux Vomica. Opium. 
Oxalic Acid. Oysters. Phosphorus. Pilocarpin. 
Prussic Acid. Quinine. Salicylates. Salicylic Acid. 
Silver. Silver Salts. Snake Bite. Strophanthus. 
Strychnia. Sun Stroke. 



CHAPTER I. 

INFECTIOUS DISEASES. 

The group of specific infectious diseases has become somewhat Specificity of 
enlarged within the last few years. One can properly include un- leases 13 
der this category only those diseases, presenting definite clinical 
and anatomic phenomena, that are caused by one specific microbe. 
This list now comprises the following diseases : 



Diphtheria 

Tetanus 

Typhoid fever 

Cholera 

Anthrax 

Tuberculosis 

Leprosy 

Plague 

Dysentery (bacillary) 

Influenza 

Glanders (Farcy) 

Chancroid 

Recurrent fever 

Gonorrhea 

Epidemic cerebrospinal 

meningitis 
Syphilis 
Actinomycosis 
Blastomycosis 
Malaria 



Bacillus diphtherias 
Bacillus tetani 
Bacillus typhosus 
Vibrio cholerce 
Bacillus anthracis 
Bacillus tuberculosis 
Bacillus lepra? 
Bacillus pestis 
Bacillus dys enter ioe 
Bacillus influenzce 
Bacillus mallei 
Bacillus chancri mollis 
Spirillum Obermeieri 
Micrococcus gonorrhoeae 
Diplococcus intracellular is 

meningitis 
Siprochceta pallida 
Actinomycosis hominis et bonis 
Blastomycetes and Oidia 
Plasmodium malarias 



Several other diseases that we are justified in declaring to be Infectious 
due to specific microbic causes cannot, as yet, be included in the hitherto un- 
above category on account of failure so far to isolate the specific known etiology 
micro-organisms. This may be due to the ultra-microscopic size 
of the latter ; to their failure to react to ordinary methods of stain- 
ing ; to our inability to cultivate the microbes outside of the human 
body; or to the fact that these diseases are due to mixed or sym- 
biotic infections. Belonging to this group are chiefly hydrophobia, 
typhus fever, yellow fever, German measles, measles, scarlet fever, 
chicken pox and small pox. 



18 



INFECTIOUS DISEASES 



Pathogenic 
bacteria pro- 
ducing miscel- 
laneous clinical 
syndromes 



General indica- 
tions for treat- 
ment 



The natural 
defenses of 
the organism 



In most of the above specific diseases certain organs or groups 
of organs are invariably involved in the disease process. Besides, 
we know of a number of infectious micro-organisms of established 
morphologic and bacteriologic characteristics as streptococci, 
staphylococci, bacterium coli, etc., that cause inflammation in 
various parts of the body without any regularity or constancy and 
do not always involve the same organs or groups of organs, hence 
do not produce uniform clinical syndromes. 

Acute infectious diseases are in a sense self -limiting and dis- 
play a tendency towards spontaneous recovery. The chief duty of 
the ph} T sician, therefore, must be to imitate the methods put for- 
ward by Nature towards restoring normal conditions, whenever 
that is possible. Wherever^ in the obscurity of our present knowl- 
edge, that is impossible, he should concern himself with creating 
ideal conditions about the patient in order to enable him to exer- 
cise his best efforts towards combating the infection. Here and 
there, besides, it may become necessary to strengthen, reinforce and 
stimulate reactive processes when they begin to flag; to hold them 
in check when they threaten to exceed safe bounds. Finally, vari- 
ous disorders about the different organs and functions of the body 
produced by the infection call for regulation and symptomatic 
treatment. 

Against all invading micro-organisms the body spontaneously 
puts forward a series of defenses that must all be overcome in or- 
der that a fatal issue be produced. These are the strong defenses 
of the body surface, the powerful inflammatory reaction at the 
point 'of invasion and finally the immensely potent antimicrobic 
and antitoxic function of the body fluids and the body cells. 

These are to be considered an active and a passive, au acquired 
and a natural, immunity; the role of leucocytes, of bacteriolytic 
and antitoxic enzymes, etc. Whatever specific methods, chiefly of 
a sero-therapeutic nature, have been worked out to the point of 
practical utility in prophylaxis and treatment, to reinforce Nature 
in this manifold struggle against microbian invasion, will be dis- 
cussed in the immediately succeeding pages. 



Sero-therapy 
classification 
Active im- 
munization 



PROPHYLACTIC INJECTIONS. 

Sero-therapeutic measures may be classified as follows:* 
A. Active immunization, in which vaccination and protective 
inoculations are included, as with the organisms of typhoid, cholera 
and plague. Depending on the material injected, the result is the 



*I am indebted for this classification to the excellent monograph 
entitled "Infection, Immunity and Serum Therapy," by the late lament- 
ed H. T. Ricketts. 



INFECTIOUS DISEASES 19 

formation of antitoxins or antimicrobic substances (amboceptors) ; 
agglutinins are formed incidentally. 

1. Inoculation of virulent organisms, (a) Inoculation with Inoculation of 
small amounts of a virulent organism, i. e., of a non-fatal dose; organisms 
used principally in experimental work, (b) Inoculation with viru- 
lent organisms into a tissue which has some natural resistance. The 

success of vaccination against smallpox by using virus obtained di- 
rectly from the diseased, a method which was practised in earlier 
times, was probably due to the fact that the virus found unfavor- 
able conditions for the development of virulence in the skin. In 
some instances immunization is accomplished more successfully by 
inoculation of bacteria or toxins into the blood stream, as in 
Kitt's method of vaccination against symptomatic anthrax and in 
immunization with rattlesnake venom. 

2. Injection of attenuated virus or toxin. Attenuation may Injection of 
be accomplished by air and light (chicken-cholera, Pasteur) ; by virus 
cultivation at high temperatures (anthrax, Pasteur) ; by chemical 

agents (anthrax, Eoux; diphtheria and tetanus toxins, Behring and 
Eoux) ; by desiccation (rabies, Pasteur) ; by passing the virus 
through other animals (swine erysipelas, Pasteur). This last ob- 
servation was a most instructive one; passing the bacillus through 
the rabbit several times increased its virulence for the rabbit but 
decreased it for swine, while passing the organism through the dove 
increased its virulence for swine. 

3. Injection of killed organisms (anthrax, Toussaint; swine ? n J e *?* on of 
plague, Salmon and Smith). This is the safest means of vaccin- ganisms 
ating against cholera, typhoid and plague. In the Pasteur treat- 
ment of hydrophobia the first injection of the dried spinal cord 

probably contains the killed virus. 

4. Injection of bacterial constituents: (a) Bacterial cell plasm Injection of 
(Buchner's plasmin, obtained by submitting micro-organisms to s tituents 
high pressure, and Koch's tuberculin, TR) ; (b) soluble bacterial 

products (the bacterial proteins, as Koch's old tuberculin and mal- 
lein; the soluble toxins; products of bacterial autolysis). When 
toxins are injected antitoxins are formed. The autolytic products 
of some organisms, e. g., typhoid and dysentery, cause the forma- 
tion of bactericidal amboceptors and agglutinins, but not anti- 
toxins. 

B. Passive immunization: The prophylactic injection of anti- Passive im- 
bacterial and antitoxic serums. munization 

C. Mixed active and passive immunization: The simultaneous Mixed active 
injection of an immune serum with the corresponding organism, feminization 
which may be killed or living. The serum causes immediate, though 
temporary, resistance, and, in the meantime, an active, more perma- 
nent immunity develops as a consequence of the injection of the 



20 



INFECTIOUS DISEASES 



organisms. This method has been practised with swine plague, 
swine erysipelas, rinderpest, and experimentally in typhoid, cholera 
and plague. 



Curative active 
immunization 



Curative 

passive 

immunization 



Ehrlich's lateral 
chain theory 



General 
hygiene 



CURATIVE INJECTIONS. 

A. Active immunization. 

1. Injections of killed micro-organisms in small doses with 
the intention of hastening antibody formation, as suggested by 
Fraenkel in the treatment of typhoid fever; value fully demon- 
strated. 

B. Passive immunization. 

1. With antitoxic serums : Diphtheria, tetanus, snake bites, 
plague, tuberculosis (?), typhoid (?), streptococcus infections (?), 
etc. 

2. With antibacterial serums : Typhoid, cholera, plague, dysen- 
tery, streptococcus (?), staphylococcus (?) and pneumococcus (?) 
infections. 

The idea underlying all antitoxic medication is best illustrated 
by the now classical Ehrlich's side-chain theory; it is based on the 
observation that the antitoxins that are formed after the injection 
of toxins are not simply produced in sufficient quantity to equal 
the amount of toxin injected, but as a rule in enormously increased 
quantities. The organism, roughly speaking, reacts to the in- 
vasion of a toxin by the formation of an antitoxin, and the original 
stimulus that led to the formation of this antitoxin ultimately 
produces an over-production of the latter ; hence under special con- 
ditions the blood of an animal so prepared contains antitoxic bodies 
that can be utilized in therapeutics. 

The technic of antitoxin preparation, the standardization of 
toxins, the preparation and combination of antitoxic sera and their 
preservation and the standards of purity of therapeutic sera need 
not be specifically described in this volume. 

Provided the broad principles of hygiene and of the general 
management of the patient afflicted with an acute infectious disease 
are understood and carefully applied, the basal treatment of most 
infectious diseases, for which we possess no specific remedy, is 
very much alike. In order to avoid unnecessary repetition a few 
general remarks in regard to the rationale of fever treatment, and 
in regard to the principles that should underly the arrangement 
of the fever diet may be discussed in this place. 



Treatment of 
fever 



THE TREATMENT OF FEVER. 

The treatment of the fever is an important element in all acute 
infectious diseases. It is essential to realize that the fever, pro- 
vided it is not too high nor too persistent, does not seriously dam- 



INFECTIOUS DISEASES 21 

age the organism. In fact, the febrile reaction must be considered Fever a salu- 
one of Nature's most effective means of combating the infection. ary reac lon 
Interference on the part of the physician is required, therefore, 
only if the febrile reaction exceeds safe bounds. The old idea that 
the fever must at all costs be kept down was based on the erroneous 
view that the parenchymatous changes seen in many organs during 
the course of acute infectious diseases were produced by the high 
temperature. Nowadays, we have learned to recognize that these 
lesions are caused by the action of circulating bacterial toxins. 

Upon the onset of an infectious fever the high temperature The normal au- 
is produced not only by an increased manufacture of heat but also mechanism^ 1 
by a decreased radiation of heat. The loss of heat is inhibited 
chiefly by contraction of the cutaneous vessels, so that early in most 
infectious diseases the skin becomes cool and the patient suffers 
a chill. Sometimes this reaction presumably suffices to abort the 
infection. If this preliminary condition were to continue through- The initial 
out the course of the disease the patient's temperature would rise 
to unsafe limits; consequently, the radiation of heat is automatic- 
ally resumed very soon after the initial chill chiefly by two paths, Radiation of 
namely, by the pulmonary and the cutaneous routes. This adjust- pu i m0 nary and 
ment must be considered as a self-regulating mechanism. Inas- the cutaneous 
much as the increased production of C0 2 which accompanies the 
initial febrile rise stimulates the respiration, more rapid breath- 
ing occurs, more water is exhaled and considerable heat is lost in 
this way (each gramme of water evaporated in the expired air 
causing a loss of about 575 calories). The loss of heat through 
the skin is promoted by sweating and the evaporation of surface 
water. (Sweating during the crisis serves a different purpose; it 
must be considered as an endeavor on the part of the organism 
to rapidly get rid of the surplus water which was retained in the 
blood and tissue juices during the fever in order to maintain 
proper osmotic equivalents) . 

In cases suffering from excessively high degrees of fever these Fresh, cool air 
methods that Nature spontaneously puts forward must be imitated, therapy r °" 
The pulmonary radiation of heat must be encouraged by supplying 
plenty of cool, fresh air (see Section on Pneumonia) . The cutane- 
ous radiation must be aided chiefly by hydriatic means (see Section 
on Typhoid) . 

In addition certain remedies can be employed for their anti- Antipyretics 
pyretic effect. Here what may be called "central" as against 
"peripheral" regulation of the temperature is attempted, inasmuch 
as most antipyretic drugs act on the central nervous elements and 
paralyze the heat centers. In the latter case, therefore, the manu- 
facture of heat is reduced, whereas by the former method the radia- 
tion of heat is increased. 



22 



INFECTIOUS DISEASES 



General indica- 
tions and 
contra-indica- 
tions for the 
use of antipy- 
retic drugs 



The chief anti- 
pyretics 



Quinine 
Salicylic acid 
Antipyrin and 
its congeners 
Alcohol 



In nearly all cases of acute infectious diseases one can get 
along very well without antipyretic drugs, and they should be 
given very sparingly and with great care only in extreme cases in 
which high degrees of temperature cannot be reduced by the pul- 
monary or the cutaneous route. Antipyretics should, moreover, 
only be given intermittently and always in combination with heart 
tonics. Their use is rarely called for early in the disease and they 
are useful chiefly when the tone of the heart and of the vaso-motor 
centers has begun to flag, when the self-controlling mechanism fails 
and calls for regulation by artificial means. It will generally be 
found that antipyretics exercise a much more profound and rapid 
effect precisely during these later atonic stages than during early 
sthenic periods of the infection. 

To enumerate all the antipyretic drugs that can be employed 
(and to this class, broadly speaking, belong remedies that act di- 
rectly on the fever-producing toxins like quinine and salicylates, 
drugs that paralyze the muscles (curare), drugs that paralyze the 
peripheral capillaries and hence promote increased radiation) is 
unnecessary. The chief antipyretics to be employed are quinine, 
salicylic acid, antipyrin and its congeners,, and alcohol. The dose 
and administration of these drugs and of certain other antipyretics 
will be discussed below in their appropriate places. 



The fever diet 



Caloric re- 
quirements of 
febrile organ- 



THE FEVER DIET. 

The most important element in the feeding of febrile cases is 
to maintain the albumen content of the organism. The amount of 
albumen consumed by a fever patient and the degree of general 
emaciation that supervenes depends somewhat on the character of 
the poison and the complications that arise. To maintain complete 
nitrogen equilibrium is usually a very difficult task. The attempt, 
however, should always be made to introduce small quantities of 
albumen daily in some form, together with plenty of carbohydrate 
and some fat. Both fats and carbohydrates protect the albumens 
of the body ; the latter much more than the former, however, inas- 
much as 100 fat calories can replace only 5.4 albumen calories, 
while a hundred carbohydrate calories can replace 15.4 albumen 
calories. 

The demand for food is decreased in febrile cases and its as- 
similation interfered with; at the same time the individual is 
quiescent and performing no labor, so that the total caloric require- 
ment, despite the increased metabolism, is lower than one might 
expect and can consequently be supplied much more readily than if 
the individual required a normal amount of caloric values to main- 
tain nutrition. In a subject weighing about seventy kilos the fol- 
lowing ration theoretically calculated is usually sufficient: 



INFECTIOUS DISEASES 23 

50 gm. of proteid == 205 calories 

50 gm of fat = 495 calories 

500 gm. of carbohydrate = 2,050 calories 



2,750 calories 



or about 30 calories per kilo. 



Milk 



In practice the following general rules of feeding sufficiently Eggs 
approximate the above requirements. Albumen should be supplied 
in the form of one or two eggs in some shape daily, or in the form 
of milk; the latter being the most valuable fever food of all, inas- 
much as 1,000 cc. of milk incorporate 35 grammes of proteid, 35 
grammes of fat and 45 grammes of sugar, representing a total cal- 
oric value of 650 calories. The addition of abundant carbohydrate 

to milk, in the form of sugar solutions or gruels made of milk and Sugar solu- 

. tions 
flour, barley, arrowroot, sago and tapioca, usually suffices to bring Q rue i s 

the daily ration up to the required caloric value. Proteids may Gelatinous 
also be supplied in the form of gelatins, meat jellies, etc., and other f°°ds 
liquid and semi-liquid meat products, the preparation of which 
is described in the Section on Typhoid Fever. The fats should be 
given in small quantities and supplied only in the form of cream, 
or as a little butter added to gruels, or in the small quantities of Fats 
meat fat that remain in the meat preparations that can be ad- 
ministered. Alcohol in small quantities, aside from its antipyretic 
properties, constitutes a useful food in fever cases, especially as it 
possesses very marked albumen sparing properties. 

"Water should always be given in abundant quantities in fever Water 
cases, not only in order to quench the thirst and to dilute the toxins, 
but to relieve the organism of the necessity of manufacturing water 
from its own tissues, thereby splitting up complex molecules and 
flooding the blood and tissue juices with waste products. A febrile 
patient should be offered a drink every fifteen to thirty minutes 
during the day, alternating the beverage, i. e., offering milk, soups, 
lemonade, a little wine, coffee, tea and water. 

The following fever diet, which is employed as a routine in 
the Charite Hospital in Berlin, may serve as a prototype of an 
average fever diet: 

For breakfast 500 cc. of milk sweetened with plenty of sugar 
and flavored with a little coffee. 

For dinner 250 cc. of meat broth. 

In the middle of the afternoon 500 cc. of milk, with sugar and 
coffee as above. 

For supper 250 cc. of gruel made of milk and flour. 



♦See also chapter on "Diseases of Metabolism. 



24 



INFECTIOUS DISEASES 



Distributed over these four meals 80 grammes of rolls, toast or 
zwieback. 

The following dietary constitutes a daily ration which about 
meets all requirements: 

1000 cc. of milk = 650 calories 

2 eggs = 150 calories 

400 cc. barley gruel = 200 calories 

100 g. zwieback or toast — 350 calories 

100 g. cane or milk sugar = 410 calories 

200 cc. of Tokay or port wine = 300 calories 

Total = 2060 calories 



State of the 
digestive func- 
tion 



Rectal feeding 



Toilet of the 
mouth 



In arranging a dietary, finally, the state of the digestive func- 
tions must be carefully included in the calculation. Both the fever 
and the toxemia affect the digestive organs in the sense that the 
amount of saliva and its amylolytic power are reduced, that the 
motor and secretory powers of the stomach and bowel are impaired 
and the flood of bile is decreased. 

These perversions of the digestive function are reflected in the 
loss of appetite. In cases of fever in which there is a complete dis- 
taste or aversion for food, rectal feeding (see index) may therefore 
have to be resorted to. 

An important element, finally, in maintaining the proper nu- 
trition of fever patients is to perform a careful toilet of the mouth, 
as described in the Section on Stomatitis. 

In the following pages those infectious diseases that are amen- 
able to specific treatment have been discussed in full, whereas of 
the large group of infections that must be treated by the expectant- 
symptomatic plan, only the most important and the most common 
members have been specially noted. In order to avoid useless repe- 
tition in this volume the treatment of the complication occurring in 
different organs has only been touched upon, because full symp- 
tomatic treatment of the different organ lesions is described in the 
other chapters. 



TYPHOID FEVER. 

No specific An attack of typhoid fever generally confers immunity of long 

duration, but it does not protect against a second attack. Artificial 
immunization with the endotoxin that can be obtained from typhoid 
bacilli by autolytic digestion of ground-up bacilli has not so far 
produced an antitoxic serum of practical value. 



INFECTIOUS DISEASES 25 

Two methods of serum therapy and vaccination are applicable 
in typhoid fever and both partake of the character of a specific 
prophylaxis rather than of a specific treatment. First, the injec- 
tion of an antityphoid immune serum ; second, the inoculation with 
killed cult&res of the bacilli. The antityphoid serum is very rapid- 
ly eliminated, hence confers an immunity of only short duration. 
Preventive inoculation with killed cultures, especially when con- , 

trolled by a study of the opsonic index according to the Wright 
method, has led to very much better results. 

The results obtained in the United States army from anti- 
typhoid vaccination have been exceedingly favorable and consti- 
tute a strong argument in favor of its protective value. During 
the year ending June 30, 1909, typhoid fever was sixteen times 
more prevalent among unvaccinated than among vaccinated troops. 
Up to October 1st, 1910, 418 cases of typhoid developed among 
non-immunized soldiers as against only 5 cases that developed 
among immunized troops ; of the latter four cases were so mild that 
the diagnosis remained in doubt. Up to the present time, since the 
introduction of this treatment into our army in March, 1909, over 
17,000 officers and men have become vaccinated, although the treat- 
ment is entirely voluntary. Among the eighteen thousand men 
mobilized near the Mexican line living under particularly unfavor- 
able camp conditions, only one single case of typhoid fever devel- 
oped in a teamster who had not been protected by vaccination. When 
one compares this result with the statistics of camp Chickamauga 
during the Spanish-American war, where there were 20,738 cases 
of typhoid with a mortality of 1,580 within three and one-half 
months, one becomes convinced of the value of this prophylactic 
treatment. No bad results have ever been seen from anti-typhoid 
vaccination, and it is to be hoped that civilian practitioners will 
soon be able to conveniently employ antityphoid vaccine as a valu- 
able prophylactic measure in threatened typhoid epidemics. 

It is not possible to abort or jugulate typhoid fever by the use Intestinal 
of any remedy given by mouth. Intestinal antiseptics, while they an lsep 1CS 
may be capable in the test tube of holding the development of 
typhoid bacilli in check and if used in sufficiently strong concen- 
trations to destroy them, could not exercise this effect in the living 
without serious detriment to the patient. The use of intestinal 
antiseptics cannot be condemned as useless, however, in typhoid 
fever, and some clinicians claim that they are capable of favorably 
modifying the bacterial flora of the intestine and hence forestall- 
ing or checking to some extent mixed infection and autotoxemia. 
The different intestinal antiseptics have been fully discussed in 
other sections. They are incapable of curtailing the duration of 
the disease and I consider their efficacy as quite problematical. 



26 



INFECTIOUS DISEASES 



Calomel Of all intestinal antiseptics calomel, if given early in the dis- 

ease, is the most useful one, and it seems to exercise a favorable 
effect in some cases upon the development of the local lesions in 
the intestine. It is best to give calomel at once in two or three 
doses of two or three grains. Later in the disease calomel is rarely 
indicated, excepting possibly in severe cases of meteorism in which 
small (one-quarter or one-half grain) doses, given two or three 

Yeast times a day, are useful. Yeast is also used extensively to modify 

the intestinal flora, and the results occasionally observed from the 
use of this remedy are sufficiently encouraging to warrant its 
employment in typhoid fever. It can certainly never do any harm. 
Yeast, in contradistinction to calomel, should be given throughout 
the course of the disease. 

With the exception of remedies that are occasionally neces- 
sary to treat cardiac failure, intestinal hemorrhage, profuse diar- 
rhea, distressing cerebral symptoms, etc., drugs altogether have a 
very subordinate place in the treatment of typhoid fever. 

Antipyretics Now and then it becomes necessary to use antipyretics in those 

cases in which the fever is very high and does not yield promptly 
to hydrotherapeutic means, or in which the patients bitterly ob- 
ject to the use of hydrotherapeutic measures^ so that an attempt 
must be made to relieve them for a time of the necessity of being 
bathed or sponged. Judiciously given, certain antipyretics reduce 
the blood temperature, quiet the heart, free the sensorium, promote 
sleep, encourage the appetite and often increase the patient's com- 
fort. Only two antipyretics can be considered safe, namely, quinine 
and lactophenin. Antipyrin, acetanilid, phenacetin are generally 
dangerous in typhoid fever, for if given in doses sufficiently large 
to reduce the temperature appreciably they increase the stupor 
and depression, reduce the flow of urine, weaken the myocardium 
and often produce chills, sweats, cyanosis and collapse. 

Lactophenin Lactophenin, however, is the one phenacetin derivative that, 

in my experience, can be safely used in typhoid. It should be 
given in doses of ten to fifteen grains four or five times in the 
twenty-four hours. It generally produces a drop of two or three 
degrees in the temperature, and induces sleep and euphoria. 

Quinine The best and the safest antipyretic drug of all is quinine. It 

should be given in the dose of fifteen to forty grains in two or three 
divided doses inside of two hours in the evening every other day. 
Within ten or twelve hours a temperature drop of two or three de- 
grees is usually brought about ? so that the temperature on the next 
morning is low. During the course of the day the temperature 
slowly rises again, but rarely reaches the same height that it 
would have reached if quinine had not been administered the eve- 
ning before. During the quinine days bathing or sponging should 



INFECTIOUS DISEASES 27 

not be instituted. Occasionally disagreeable, but not dangerous, 
symptoms, as buzzing in the ears, tremor, light-headedness, and 
diarrhea may follow the use of quinine. 

The most important elements in the treatment of typhoid Diet 
fever are the diet and hydrotherapy. The diet should be exclusive- 
ly liquid during the fever period, and for a week or ten days there- 
after. The food should be digestible, non-irritating to the bowel 
and it should leave a small residue. 

The ideal food in typhoid fever is milk. It should be given Milk 
in quantities of from two to three quarts a day, preferably diluted 
with water or lime water. In placing a typhoid fever patient upon 
a milk diet, the stools should be examined every day for curds, and 
if the latter appear the milk ration should be reduced, or, if neces- 
sary, stopped altogether. Some people have a marked aversion to 
milk. In such cases it is bad practice to force milk drinking and 
it is well to realize that the patient can very adequately be nour- 
ished for several weeks on a liquid diet if no milk is given or some 
of the other foods, to be presently described, are administered in its 
stead. An attempt should, nevertheless, be made to accustom the 
patient to the use of milk or milk foods. If the milk is given * 
very cold in small quantities and at frequent intervals, many pa- 
tients gradually learn to relish and to tolerate it. If this can be 
accomplished within a few days, then the amount of milk given at 
each feeding may be increased and the intervals of feeding short- 
ened, so that in this way the full quantity may be ultimately ad- 
ministered. Occasionally the addition of a little coffee/ or brandy, 
or egg to the milk renders it more palatable so that the patients can 
take it in this form. 

In addition to milk diet and substitutes for milk, the patients Gruels 
may have gruels made from barley, arrowroot, rice and oatmeal, 
that are carefully strained and to which are added a little butter 
and salt. A little yolk of egg, or some meat juice, meat broth or E SS S 
meat extract as a flavor, or beef broth with egg to which is added Meat broth 
flour made of wheat, rice, sago or barley, may be given. 

One of the most useful preparations is raw meat juice made Raw meat juice 
by expressing in a meat press beef that has been cut into small 
pieces. The juice is of a light-red color and possesses a slightly 
acid reaction. As it readily decomposes it should be kept on ice and 
should be prepared fresh every twenty-four hours. The patient 
should receive from 3 to 6 ounces of this meat juice in the 
twenty-four hours. In order to administer this amount, one or two 
tablespoonfuls of the meat juice should be added to the ordinary 
broth, or to some of the milk preparations enumerated above. In 
addition a tablespoonful of the juice should be given every two 
or three hours throughout the day. Some patients have a great 



28 



INFECTIOUS DISEASES 



Frozen meat 
juice 



Meat jelly 



Liquids 



Alcohol 



Hydrotherapy 



aversion to the meat juice and dislike its taste and odor. Here a 
peppermint lozenge chewed before the meat juice is taken often 
overcomes this repulsion. 

Another very elegant preparation of meat juice that is particu- 
larly useful in cases that cannot take the liquid preparation, and 
in patients who suffer from severe vomiting^ is frozen meat juice. 
Ziemssen recommends the following method of preparing it: 500 
cc. of fresh meat juice are sweetened with 250 grammes of sugar 
and flavored with 200 cc. of lemon juice and about 20 cc. of 
brandy; to this mixture are added three yolks of egg and a little 
vanilla. It is then frozen in an ice cream freezer. 

Meat jelly made from chicken, veal or beef is also a very grate- 
ful food for some people. The meat is chopped up fine, heated in 
a casserole to boiling temperature without the addition of any water. 
The juice solidifies as soon as it cools off and can be added to ordi- 
nary meat broth and to milk foods. It is useful more as a flavor 
than as a food. Wine jellies or other gelatine preparations are a 
very welcome addition to the diet. 

The quantity of fluid nourishment and of water need not be 
limited. Broadly speaking the more liquid a typhoid patient will 
take, the better. One should never wait until the patient manifests 
a desire to drink water or to take liquid food, but small quantities 
of liquid should be offered at frequent intervals, not to exceed half 
an hour, throughout the day, and, if the patient is awake, also 
during the night. 

Alcohol is a very useful food and stimulant and may without 
detriment be given throughout the course of the disease. It may be 
administered in the form of dilute white wine or brandy in water, 
or in the form of the very useful Stokes' brandy-egg mixture con- 
sisting of 50 cc. of brandy, two yolks of egg, 150 cc. of cinnamon 
water and 25 cc. of simple syrup. This quantity should be admin- 
istered in divided doses in the course of twenty-four hours. Many 
patients enjoy hot tea with a little rum or a little champagne. 
Claret or burgundy should not be given cold, because a cold alco- 
holic solution of tannin is irritating to the walls of the stomach and 
bowel. Given hot, however, burgundy flavored with sugar, cinna- 
mon and cloves is a very useful stimulant and astringent and acts 
particularly well in meteorism; 250 to 500 cc. of this drink may 
safely be given. Lemonade is a very useful beverage, especially as 
the ethereal oil of the lemon stimulates the flow of saliva and hence 
keeps the mouth moist. 

Hydrotherapy occupies the most important place in the treat- 
ment of typhoid fever. Water treatment acts favorably not only 
by reducing the temperature but by exciting the nerves of the cir- 
culatory apparatus, by its action on the vaso-motor system and by 



INFECTIOUS DISEASES 29 

its stimulating effect upon the nervous elements supplying the vari- 
ous organs. It counteracts functional inadequacy and parenchy- 
matous changes in many important organs that are commonly af- 
fected in typhoid fever. The vaso-motor effect is particularly im- 
portant in all infectious diseases ; in typhoid fever especially as there 
is always danger of paralysis of the vaso-motor centres. Upon the 
respiratory centres cold hydrotherapeutic measures also exercise a 
very pronounced effect. By means of cold applied to the surfaces 
of the body deeper breathing is generally produced and as the 
heart's action is at the same time strengthened, the occurrence of 
bronchitis and pneumonia is effectually prevented. Upon the ner- 
vous system hydrotherapy also has a most pronounced influence. 
It is the sovereign remedy to rouse patients from the stupor they 
are apt to lapse into in typhoid fever. Hydrotherapy judiciously 
applied improves the appetite, promotes sleep and by keeping the 
patient aroused and active renders his care easier, prevents decu- 
bitus and, to a certain extent, the development of disagreeable 
mouth complications when the stuporous, somnolent patients no 
longer voluntarily perform swallowing or chewing movements. 

The following general rules in regard to the application of General rules 
hydrotherapeutic means may be formulated : The thermic stimulus 
should be as energetic as the patient can tolerate and it should, 
in every case, be reinforced by producing artificial dilatation of the 
cutaneous vessels by friction of the patient's skin while he is im- 
mersed in the water. It is good practice to begin with mild hydro- 
therapeutic means and then gradually to adopt more severe ones or 
not according to the individual reaction of the patient. Many 
methods of hydrotherapeutic treatment in infectious diseases can 
be adopted. 

In hospital practice the severer methods are commonly em- Brand treat- 
ployed, especially the orthodox Brand treatment, which consists in 
giving the patient a full bath of 70° F. to 64° F. for ten minutes 
as soon as the temperature rises over 103y 2 ° F., rive to six of such 
baths being given a day. In private practice this method is more 
difficult to carry out because it requires a movable bath tub or a 
bath tub kept permanently in the patient's room, and also re- 
quires one or two assistants to transport the patient into the bath 
and back into bed again. In addition the patients generally bitter- 
ly complain of this treatment and object to it seriously. More- 
over, it is questionable whether this severe method possesses suf- 
ficient advantages over milder ones to warrant its employment. 
The fear of the patient and his opposition to these cold baths 
are not without detriment on account of the nervous excitement this 
opposition produces ; hence, if the full bath plan is to be adopted at 
all it is usually better to use water of moderately high tempera- 



30 INFECTIOUS DISEASES 

tures in the beginning. Here it is necessary to strictly individual- 
ize before instituting a routine bath treatment and the individual re- 
action of the patient to the different temperatures should always 
first be determined. One can begin safely with immersion of the 
patient in water of 89° F. to 82° F. (32 to 28° C.) and then 
gradually cool the bath water off to 75° to 68° F. (24 to 20° C). 
If the patient is very anemic or very sensitive, or if symptoms of 
collapse appear, then the temperature should not be allowed to go 
below this point. If the patient develops a chill while in the bath 
he should be immediately removed. No attempt should ever be 
made to reduce the temperature below normal, in fact, it is always 
a safe plan to limit the reduction of the temperature to about two or 
three degrees Fahrenheit, the patient remaining in the bath for fif- 
teen to thirty minutes, not longer. As soon as the patient is placed 
into the water energetic friction of the surfaces of the body should 
be performed, and this should be kept up during the whole time 
that the patient is in the water. If there is much respiratory dif- 
ficulty, the patient suffering from bronchitis or pneumonic symp- 
toms, then cold water should be poured over the head ? neck, chest 
and back at the end of the bath. In this way a few deep respira- 
tions are stimulated that, as stated above, act beneficially in coun- 
teracting the congestion in the respiratory apparatus. 

The drop of temperature rarely persists for longer than three 
hours after the bath, consequently, in order to produce a perma- 
nent antipyretic effect it becomes necessary to give five or six of 
such baths during the twenty-four hours. In this way the aver- 
age temperature can effectually be kept down two or three degrees. 

On removal from the bath the patient may either be wrapped, 
without drying, in a linen sheet and covered with a thin woolen 
blanket, and after a rest of fifteen to twenty minutes, the surfaces 
of the body may be dried and a dry nightshirt put on. If the 
temperature has been reduced over two or three degrees, Fahren- 
heit, however, it is usually better to rapidly dry the patient and 
to wrap him in a warmed linen sheet. Both before and after the 
bath the patient may to advantage receive a stimulant, consisting 
of a little wine or a few teaspoonfuls of hot coffee. That the pa- 
tient should be carefully transported into and removed from the 
bath need hardly be emphasized. Contra-indications to the bath 
treatment are hemorrhage, perforation, peritonitis or impending 
heart failure and collapse. 
Wet pack In private practice, and particularly among the poorer classes 

who cannot secure adequate bathing facilities, the wet pack may 
take the place of the full bath. This method of water treatment 
does not exercise so pronounced an antipyretic effect, as the full 
bath, but acts very beneficially nevertheless. The wet pack is best 



INFECTIOUS DISEASES 31 

administered as follows : A large linen sheet is wrung out of water 
of 50 to 54° F. (10 to 12° C.), the patient rapidly wrapped into 
the sheet and allowed to remain in this packing for six to ten min- 
utes. At the end of this period a second wet pack is applied and 
this procedure repeated three or four times. It is good practice to 
leave the patient in the last pack for fifteen to twenty minutes. 
The most practical method of carrying out this plan is to have 
two beds and to transport the patient from one wet pack into the 
other. 

A third method, and one that may be applied as a routine Sponging 
measure in every case of typhoid fever, immaterial whether the 
temperature rises above 102y 2 ° F. (39° C.) or not, is sponging of 
the surfaces of the body with cold water of 50 to 54° F. (10 to 12° 
C.) or with ice water to which may be added a little vinegar or 
alcohol. By carefully going over the whole body with a cold sponge 
every two or three hours the temperature can always be somewhat 
reduced, and, above all, a beneficial stimulating effect can be ob- 
tained. After the sponging the patient should, of course, be care- 
fully dried and covered with a linen sheet and a thin woolen blanket. 

It is useless to designate the many other methods of hydro- 
therapeutic treatment by means of half-baths, partial packs, etc., 
that have been described. The lukewarm full bath gradually cooled 
and combined with friction and cold douches, the wet pack, and 
sponging, always suffice to produce the desired result. 

COMPLICATIONS. 

Certain complications of typhoid fever require particular dis- Nervous com- 
cussion. About the nervous system the symptoms may either be 
those of depression or of excitement. The stupor and somnolence 
are best combated by the use of cold douches given in a lukewarm 
bath and the application of an ice-bag or a Leiter coil to the head 
either permanently or interruptedly. The symptoms of excitement 
and meningeal symptoms manifesting themselves by severe head- 
ache, delirium, restlessness, insomnia, etc., are best treated by luke- 
warm baths or, in extreme cases, by hot baths. While the patient is 
immersed in the warm water, an ice-bag or Leiter coil should always 
be applied to the head. In cases of insomnia or headache that do 
not yield readily to these simple hydrotherapeutic means, trional, 
sulphonal or lactophenin may occasionally have to be given. Opium 
and morphine, however, preferably the latter given hypodermically 
in doses not to exceed one-fourth of a grain, two or three times a 
day, are the best remedies. 

One of the chief dangers in typhoid fever is circulatory failure, Circulatory 
either gradually progressive or sudden. The tendency to heart al ure 
failure, manifesting itself by a rapid small pulse, low blood pressure, 



32 



INFECTIOUS DISEASES 



Diarrhea 



Mcteorism 



a cool skin, a pale face and later cyanosis, must be energetically 
counteracted by various remedies. Best of all in the gradually 
developing cases is alcohol administered in the form of brandy, hot 
claret with spices or, better yet, champagne, the latter to be given in 
liberal doses. Strychnine, too, given in doses of one-thirtieth of a 
grain every three or four hours is a useful remedy in this condition. 
Digitalis should be given with great care and preferably not at all 
on account of the danger of myocarditis. In sudden heart failure, 
camphor is the sovereign remedy. It may either be given in ten per 
cent, ethereal solution in the dose of ten to twenty drops hypoder- 
mically, and frequently repeated until the heart's action improves, 
or in the form of a ten or twenty per cent, solution in sterile olive 
oil, a syringe full of this solution to be injected hypodermically 
every one and one-half to two hours. Adrenalin chloride, in ten per 
cent, solution, twenty to thirty drops hypodermically, also occa- 
sionally aids in combating sudden heart failure. The ice-bag over 
the heart, or a Leiter coil, preferably applied intermittently, is also 
useful in these cases. 

Certain symptoms about the intestinal tract may require special 
attention, particularly diarrhea and meteorism. If the patient has 
four or five liquid stools a day this mild form of diarrhea requires 
no special treatment, but if more than five movements in the day 
are deposited, then the frequency of the motions should be reduced. 
The best remedy is opium, which should by preference be given per 
rectum in a starch enema as follows: Ten to fifteen drops of the 
tincture of opium dissolved in two ounces of starch water (one table- 
spoonful of starch to eight ounces of water) should be injected every 
two or three hours through a high rectal tube until the diarrhea is 
checked. It is best to refrain from the administration of opium or 
tannin by mouth on account of the irritating effects these remedies 
exercise upon the gastric mucosa. Bismuth subnitrate in ten to 
fifteen grain doses, given every two or three hours, may, however, to 
advantage be combined with the rectal opium treatment. 

Excessive meteorism is a very distressing symptom and one that 
it is difficult to treat. The expulsion of the gas may frequently be 
promoted by inserting a high rectal tube and in this way preventing 
the contraction of the sphincter. A Leiter coil or an ice bag should 
be applied to the abdomen in some cases while in others hot applica- 
tions, especially flannel cloths wrung out of hot water to which a 
few drops of turpentine are added, are more grateful to the patient 
and more effective in overcoming abdominal distention with gas. 
Enemas of warm physiological salt solution, containing from three 
to five drops of turpentine to the quart, may be injected and drop 
doses of turpentine, preferably in a little milk, may also be given by 
mouth. A teaspoon of freshly prepared milk of asafetida added 



INFECTIOUS DISEASES 33 

to a pint of warm water and administered by rectum very effectively 
promotes the expulsion of gas from the bowel. 

Constipation is usually a negligible symptom unless it persists Constipation 
for more than two or three days. It does not often supervene if the 
initial large dose of calomel mentioned above is given. It is always 
best to attempt evacuation of the bowels by soap suds or turpentine 
enemata. If any laxative is given it should be a saline, i. e., a 
Seidlitz powder, magnesium or sodium sulphate. 

Hemorrhage from the bowel requires energetic treatment. The Hemorrhage 
patient should be put completely at rest, bathing or other hydro- 
therapeutic means stopped, and for twenty-four hours all food and 
drink withheld. Later, a little cold milk, ice pills to allay the thirst 
or a little bouillon, broth or dilute wine may be given. Ice-bags 
should be applied to the abdomen. Styptics, given by mouth or 
hypodermically, or by rectum, are not of much value in controlling 
the bowel hemorrhage in typhoid fever. The different hemostatic 
drugs will be found discussed elsewhere. 

Perforation of the bowel, with or without peritonitis, is usually Perforation 
a fatal complication. Every effort should, in typhoid fever, be 
directed towards preventing this accident by careful regulation of 
the diet, rest, avoidance of straining and coughing efforts, sudden 
movements, etc. After perforation has once occurred there is noth- 
ing to do excepting to keep the patient perfectly quiet, preferably 
with the aid of hypodermic morphine injections. In view of our 
helplessness from a medical standpoint to treat perforation, laparot- 
omy and mechanical closure of the rupture should always be con- 
sidered, especially if the accident is discovered early before 
symptoms of diffuse peritonitis have made their appearance. This 
operation has frequently been performed during late years and the 
results obtained in skillful hands have been so favorable as to war- 
rant the adoption of this radical procedure in most cases. For the 
treatment of acute diffuse peritonitis I refer to the section on this 
disease. 

Decubitus is prevented by rigid cleanliness, by keeping the skin Decubitus 
dry, by ordering the patients to frequently change their position. 
Upon the appearance of a bed-sore the air cushion should be used, 
the parts frequently bathed with alcohol, carefully dried and dressed Stomatitis 
with boric acid powder. The treatment and prevention of stom- 
atitis will be found discussed elsewhere herein. 

The treatment of recurrences is in all essentials the same as that Recurrences 
of the original attack. Here again hydrotherapeutic measures and 
the diet are the dominating features of the treatment. 

Paratyphoid, an interesting fever closely resembling mild 
typhoid, has so far not become amenable to specific serum therapy. 



34 



INFECTIOUS DISEASES 



PNEUMONIA. 



Materies 
Morbi 



(By Dr. Edward F. Wells, Chicago.) 

Significance Pneumonia is a widely prevalent and very dangerous disease; 

in temperate regions it is responsible for more deaths than any 
other malady; its prevention treatment is the greatest and most 
pressing medical problem of the day. What can we do to lessen 
its prevalence and reduce its mortality? These are the questions, 
shorn of all minor and collateral issues, which are presented for 
our careful consideration. 

Pneumonia is caused by the pneumococcus. This bacterium, 
in one or another of its varieties, you may find in the upper re- 
spiratory passages in a large proportion — probably one-half — of all 
healthy persons. It is disseminated through the air which has 
become pneumococcus-laden by the spray produced in coughing 
and sneezing, and from dried and pulverized sputum of infected, 
but not necessarily pneumonic, individuals. If such air is inhaled 
by a healthy person, the germs may find permanent lodgment in 
his nose and throat. In this locality the pneumococcus is prob- 
ably an innocent parasite, but if it finds its way into the pulmon- 
ary alveoli pneumonia results. The entrance of this organism into 
the air cells may be invited by any condition which renders paretic 
the laryngeal and bronchial reflexes. It is found in the circulating 
blood, early — I have recovered it within an hour of the initial 
chill — in a very large proportion, if not all, of the cases. Intercur- 
rent or independent pneumococcal inflammation, with sanguineous 
infection of other organs and tissues, as ? e. g., endocardium, arti- 
culations, peritoneum, etc., may occasionally occur. The various 
strains of the pneumococcus vary in virulency, and those which 
are most virile obtain the widest distribution and create the 
greatest havoc. 

Prophylaxis With the basic etiological facts fully appreciated we are pre- 

pared for an intelligent consideration of the prophylaxis of this 
malady. This I believe to be the most important and most hope- 
ful section of the whole pneumonia question, and it is commended 
to the earnest attention of the profession. 

In the case of each individual, not pneumonic, under pro- 
fessional care the tonsillar surface secretions should be examined 
for the pneumococcus. If a Gram positive encapsulated diplococ- 
cus (or streptococcus) is obtained it may be considered, for this 
purpose only, sufficient evidence of the presence of the pneumococ- 
cus. Such examinations should be repeated at intervals, in order 
to have fair knowledge whether the patient is, or is not, affected. 
Keep a record of, and report to him, your findings. With the 



INFECTIOUS DISEASES 



35 



throat free from pneumococci the individual is practically exempt 
from pneumonia. 

For the medical practitioner I recommend the following technique: Technique of 
Rub a sterile cotton swab over both tonsils; make cover-glass spreads; determination 
dry, and fix with heat. Have prepared the following solutions : of micro-or- 

ganism 

A. — Gentian violet solution: 

Saturated alcohol solution gentian violet, 

Alcohol, 

Glycerine, 

Carbolic acid solution, 95 per cent., 

B. — Iodine solution: 
Iodine, 

Iodide of potassium, 
Water, distilled, 

C. — Fuchsin solution: 

Saturated alcoholic solution fuchsin, 

Alcohol, 

Glycerine, 

Carbolic acid solution, 95 per cent., 

Water, distilled, 



6 


cc. 


10 


ce. 


10 


cc, 


4 


cc. 


1 i 


gm. 


2 | 


sjm. 


200 < 


:c. 


0.5 


cc. 


10.0 


cc. 


10.0 


cc. 


4.0 


cc. 


60.0 


cc. 



Stain the specimen with the gentian violet solution for one min- 
ute; wash well in water; apply the iodine solution for two or three 
minutes; wash; decolorize thoroughly with alcohol; wash; counter- 
stain with the fuchsin solution, heated, for one minute; wash thor- 
oughly; dry; mount; examine with one-twelfth oil immersion lense. 
Pneumococci stain intensely violet or blue, almost black at times; the 
capsules remain uncolored, contrasting sharply with the deep stain of 
the organisms and the rosy or brilliant red of the general field. When 
pneumococci lie upon or beneath an epithelial cell the capsule may 
present a pink or rosy hue, due to the staining of the cellular proto- 
plasm. Sometimes the pneumococci are in chain formation, with either 
a continuous sheath-like capsule, or with the ends of the diplococcal 
capsules joining end to end. The streptococcus mucosus (capsulatus) 
takes this (Gram) stain, as found alone in some cases of pneumonia, 
ferments inulin, coagulates inulin-water-serum and should be classed as 
a variety of the pneumococcus. All streptococci retain the stain well; 
staphylococci and diphtheria bacilli stain in lighter shades; tubercle 
bacilli stain a deep or brilliant red; Friedlander's bacillus and the in- 
fluenza bacillus are stained pink or rosy red. 

The capsule of the pneumococcus may be stained with Wright's 
or other methylene-blue-azure stain, or by Rosenow's, Welch's or 
His's stain. Differentiation may be more closely made by various cul- 
tural, fermentation, agglutination and animal inoculation tests, a con- 
sideration of which is beyond the scope of this treatise. For further 
information reference is made to the current literature. 

If pneumococci are not found in the throat every reasonable 
precaution should be taken to prevent future infection. The mouth, 
nose and throat should be kept as clean as possible. Unclean 
fingers, money and other articles which are promiscuously handled, 
should be kept out of the mouth. Antiseptic nasal sprays, mouth- 
Avashes and gargles may be used. The teeth and mouth generally 
should be frequently and carefully cleansed ; water should be swal- 
lowed after eating; mouth-breathing should be avoided. The nasal 
passages should be kept as free as practicable from accumulations 



36 INFECTIOUS DISEASES 

of mucus; if there are organic obstructions they should be re- 
moved. Hypertrophied and honeycombed tonsils should be ablated 
or otherwise properly treated. Extraordinary efforts should be 
made to avoid crowds of coughing and sneezing persons, and to keep 
well beyond the range of possibly pneumococcus-laden air. Eesi- 
dence in regions where the pneumococcus is rare may be con- 
sidered. The obvious intent in instituting all these measures is, 
as must be evident, to avoid or minimize the risks of invasion, or 
prevent lodgment of the pneumococcus in the upper respiratory 



If the pneumococcus once finds infective lodgment in this reg- 
ion it remains, so far as I know, a permanent resident, impossible 
of dislodgment by any known means. The individual is now liable 
to pneumonia at any time, although he may pass through life with- 
out an attack. Under these circumstances, notwithstanding our 
best efforts, pneumonia cannot always be prevented; it may, how- 
ever, be invited, and such invitation should not be intentionally 
extended. 
Communal In the case of the infected person the measures above recom- 

pro ection mended for the uninfected should be followed, with the hope that 

the virulency of the organism may be reduced, and that the infec- 
tion may be least likely to extend to others. He should, in addition, 
avoid injury to the mucous membranes of the nose, mouth and 
throat; the excessive, and even the so-called moderate, use of al- 
cohol, or any other drug which will render paretic the reflex nerves 
which stand sentinels at the portals of, and along the course of ? the 
deeper respiratory tracts. For the same reason undue exposure to 
cold and inclement weather; privation; physical and mental ex- 
haustion; profound sleep when chilled or over-tired; all should be 
avoided. The chances of contracting disease, as, e. g., typhoid 
fever, measles, smallpox, etc., which may lay the foundation for 
pneumonia, should be minimized; should they develop special at- 
tention should be given to the preservation of the respiratory re- 
flexes. Anesthetics should be employed with caution, and only 
after careful preparatory cleansing of the nose, mouth and throat, 
and the administration of a stimulant, such as strychnia, to the 
respiratory reflexes. 

Impressively advise those who harbor the pneumococcus to care- 
fully avoid disseminating the infective organism, and patiently in- 
struct them how this may be done. Such persons should, in cough- 
ing, sneezing and blowing the nose hold a moistened cloth before 
the mouth and nostrils in such manner as to prevent the projec- 
tion into the surrounding air of the fine, probably pneumococci- 
bearing spray which ordinarily follows these explosions. In pneu- 
monia the sputum which clings so persistently to the teeth and lips, 



INFECTIOUS DISEASES 37 

and that which may adhere to the fingers and bedding, should be 
wiped up with moistened gauze or other cloth and these burned. 
That which is freely expectorated should be caught in a vessel 
which may be boiled, thus destroying the germs and cleansing the 
receptacle. In some efficient manner all sputum should be de- 
stroyed. A room which has been occupied by a pneumonic patient 
should be disinfected. 

For additional communal protection there should be displayed 
in all public places placards bearing the legend: 



KERCHIEF BEFORE TOUR MOUTH AND NOSE/ 



In addition, the advice given in the preceding paragraph, 
formulated into plainly stated and available rules, should be wide- 
ly and persistently circulated among the laity by the responsible 
health officers. A supply of these rules, neatly printed, but without 
imprint, should be furnished practising physicians, with the re- 
quest that they give them as their instructions to their patients and 
clientele. 

Finally, not only maintain your own enthusiasm in this matter, 
but by every means within your power arouse and foster the inter- 
ests of other physicians and humanitarians in this subject. For 
example, take the initiative in organizing special committees and 
societies for the purpose of stimulating the study of the problem 
and reinforcing the efforts of the various health bodies, as has been 
so successfully done in the case of tuberculosis. 

At this point it behooves the conscientious physician who may 
be called upon to treat cases of pneumonia to take stock of himself in 
order that he may decide whether he should, in all fairness, assume 
such a grave responsibility. If he possesses the necessary knowledge; 
if he has observed and managed a number of cases of this disease; if 
he has sufficient physical endurance; if he is free from impairing drug 
habits; if he has at all times a good and unclouded judgment; if he 
has executive ability; if, in addition, he possesses self-confidence he 
may safely undertake the management of cases of this serious malady. 
On the contrary if, because of lack of opportunity, inherent incapac- 
ity, or acquired habits, he finds himself lacking in the above essentials 
he should decline to treat these cases. 

With the failure of preventive measures and the development 
of pneumonia, how shall the patient be managed that his every in- 
terest may be best conserved? 

Assuming that your patient is a middle-aged adult, of previous initial care 
good health ; with no drug habits ; in easy pecuniary circumstances ; 
that the environment is ideal; that you see him at the beginning 



38 



INFECTIOUS DISEASES 



First medica- 
tion 



The sick room 



Nurse 



of the attack; that the diagnosis is made; under these conditions 
much is required and much is to be done at the first visit. 

At the beginning of the attack the patient should be placed 
in bed, surrounded by bottles of hot water, and given, hypoder- 
mically, one-twelfth or one-eighth grain of morphia, for the pur- 
pose of relieving the pain, allaying nervous excitement and restor- 
ing circulatory equilibrium. He should lie quietly until the chill 
has subsided, when the hot water bottles should be removed and 
the perspiration wiped from the surface of the body. The bowels 
should now be evacuated by an enema of two ounces of Epsom 
salts, two ounces of glycerine and twelve ounces of water; later an 
efficient cathartic should be given. 

The sick-room should be large, well ventilated and with south, 
east and west exposures. It should be comfortably furnished, in- 
cluding, preferably, two narrow beds of suitable height. Bathroom 
and other modern conveniences should be adjacent. There should 
be provision for regulating the temperature, that the air may be 
comfortably warmed in winter and cooled in summer. 

A nurse and an assistant will be required. The nurse should 
have inherent ability, diligence, acute observation, good judgment, 
abundance of reserve capacity, excellent training and reasonable 
experience. Her assistant should be thoroughly competent. She 
should be given written directions, which may be, approximately, 
as follows : 



DIRECTIONS FOR THE NURSE. 

1. — Follow the ordinary rules of good nursing, including, particu- 
larly, keeping awake, alert, attentive and closely observant at all times; 
keeping of full and accurate records; the prompt report of striking, 
unexpected or important changes as they occur. 

2. — Keep the room at an equable temperature, 60° to 70° F., as may 
be agreeable to the patient. The humidity should be moderate. The 
air, coming from the outside, should be fresh and pure. There are 
no objections to agreeable odors. 

3. — Promiscuous visiting should be prohibited; no one should be 
admitted to the sick room except those specifically designated by the 
physician. The consideration of business problems is highly objection- 
able. Quietude of mind and body should be favored by maintaining a 
general confident air of hopefulness. 

4. — The patient should be confined to his bed; his position should 
be changed often, but in such manner as to cause the least discomfort; 
he should be generally handled with gentleness, in bathing, in the use 
of the bed-pan, in changing his clothing, etc. The narrow bed should 
be so placed as to permit approach from either side; one bed should 
be used during the day, the other at night; in moving the patient from 
one to the other bed, place the beds side by side and slide him across 
with the sheet, two persons being necessary. The mattress should be 
elastic, the pillows soft, the sheets of soft goods, and the covers light. 
The night-dress should be of soft cotton, thin woolen, or silken goods, 
and so arranged as to afford easy access to all parts of the chest. 

5. — The surface of the body should be bathed twice daily with 
warm water, to which a little Cologne water has been added. If 
there is a tendency to chilliness the bathing should be done under the 
covers. The face and hands may be bathed as often as required. If 



Infectious diseases 39 

there should be much perspiration the surface should be wiped dry, 
gently rubbed with a cloth dampened with alcohol and a drying pow- 
der applied. The ice cap should be used if the temperature runs high, 
or if the head aches, provided it is not disagreeable. The hot water 
bottle, or the electrotherm, should be used if the extremities become 
cold; if agreeable they may be applied to the painful side. 

6. — The patient should be encouraged to restrain ineffectual cough- 
ing as much as possible. The expectoration should be caught upon 
moistened gauze and preserved for the physician's inspection; that 
which clings to the lips, or falls upon the floor or clothing, should be 
wiped up; all sputum should be destroyed before it has become dried. 
The mouth should be kept clean. All utensils, and other articles 
which come in contact with the mouth or sputum, should be scrupu- 
lously cleansed and disinfected. Later the room should be disinfected. 

7. — Nourishment should be given as follows: Pour times a day, at 
six hourly intervals, the patient should be given one egg, a piece of 
toast and a glass of milk. The egg may be given in any form desired. 
The milk may be cold or hot, peptonized, fer lented or soured, or in 
the form of milk soups, cocoa, caffe an lait, tc, as required to meet 
the tastes or digestive needs of the patient. Three hours after each of 
these feedings there should be given a half-pint of well seasoned and 
agreeably flavored weak beef, mutton or chicken broth. At other times 
there should be given water, carbonated waters, fruit juices, tea, coffee, 
etc., to such an extent that the patient receives a total of about sixty 
to seventy ounces of liquids, of all kinds, in the twenty-four hours. 
Salt should be freely used. If nausea or vomiting preclude gastric 
nourishment enemas, to be retained, of eight to ten ounces of coffee, 
with forty grains of table salt should be administered every four to 
six hours. 

8. — The first night give two five grain pills of blue mass, followed 
next morning by a half bottle solution of citrate of magnesia. Later 
the bowels should be made to move twice daily by enemas; that in the 
morning should be a large normal salt flushing one; that in the eve- 
ning should be the stimulating one of sulphate of magnesia and glyc- 
erine above mentioned. The latter enema should be used at any time 
if there should be flatulency, or intestinal paresis with abdominal dis- 
tention. The mixed twenty-four hours' urine should be preserved and 
a two-ounce specimen, and one ounce of recently passed urine, fur- 
nished the physcian daily for analysis. 

a. — The patient should be given every needed and ordered service, Notes 
but excessive and fussy attention should be avoided; he should be al- 
lowed sufficient rest when awake, and should not be awakened from 
sleep. There should be no rattling of utensils nor clattering noises al- 
lowed. In his presence the patient should have the undivided atten- 
tion of nurse and physician; for the time being he is the center of 
the world. 

b. — The nurse should be especially instructed as to the significance 
of certain symptoms and conditions, and as to the initial management 
of some of the most serious complications. In some cases of observ- 
ant delirium the patient should be very closely watched, in order that 
he may not elude vigilance and escape. In the slight but gradually in- 
creasing duskiness of the surface, and blueness of the nails, of early 
cyanosis, oxygen should be promptly administered. In the spreading 
ashiness of the surface, with changed character of the cough and serous 
expectoration of pulmonary edema, the foot of the bed should be raised 
sufficiently high to make the mouth and nostrils the lowest portion of 
a draining inclined plane, and a hypodermic injection of one-twelfth 
grain of morphia, one one-hundred and fiftieth grain of atropia and 
one-thirtieth grain of strychnia should be immediately given; and the 
physician should be immediately notified. In the late surface glow, 
with increasing frequency of the pulse and slight capillary and venous 
pulse, which is the beginning of a dangerous vaso-motor paresis, there 
should be administered, under the skin or deeply in the muscles, one 
or more syringefuls of a five per cent, solution of camphor in sterilized 
olive oil. It is needless to say that proper provision should be made 
for all these, and other contingencies. 



40 



INFECTIOUS DISEASES 



Morbid pro- 
cesses 



Abortive cases 



c. — The nurse should be informed that late sneezing is of good 
augury; that the slight respiratory click, which does not attract the 
attention of observers generally, and which promptly returns after being 
silenced by a cough, is of ominous import. 

At this place it may be well to make some preliminary state- 
ments which will clear the way for more rapid progress : 

Have we an efficient specific treatment of pneumonia? It is 
well known that the pneumococcus, in the blood, and in the hepa- 
tized lung, produces certain substances which are as yet known only 
by their effects, as e. g., the initial chill and nervous shock; the 
prompt occurrence of capillary dilatation and polynuclear leucocy- 
tosis; later the appearance in the intra-and extra -vascular serum 
of a specific agglutinir ; and yet later the production of a toxin 
which speedily causes the pneumococcus to disapepar from the 
blood. These facts have led to reasonable expectations that there 
might be prepared an antipneumococcic serum which, when in- 
troduced into the circulating intra- and extra-vascular serum of the 
pneumonic patient would speedily,, and certainly, cure the disease. 
Either by inducing a very active, and protective, immunization, or 
possibly, the rapid destruction of the pneumococci in the blood and 
inflamed pulmonary area. In my opinion, such sera, reliably ef- 
ficient, have not yet been produced. It is noticeable that, with a 
profession eagerly awaiting the advent of such sera, those thus far 
placed upon the market have signally failed to meet that favor at 
the hands of clinicians which is quickly and enthusiastically award- 
ed therapeutic novelties of real value. However, analogy leads 
us to believe that a useful antipneumococcic serum may be pro- 
duced, and I remain hopeful that this will be early accomplished. 

The pneumonic crisis corresponds so closely in point of time 
to the extinction of the infecting organism that we are forced to 
the conclusion that, although immunization may tide over a period 
of peril, nevertheless it is the death of the pneumococci, and not 
simply the neutralization of their toxins, which is the event which 
must precede recovery of the patient, and experiments only strength- 
en this conviction. A pneumonia antitoxin is, therefore, not to be 
expected, and none has been produced which has attracted any 
favorable therapeutic consideration. 

The abortion of pneumonia has always attracted much atten- 
tion. In the ephemeral cases^ with recovery in one, two or three 
days, there is probably infection by a very weak strain of the 
pneumococcus, which is early and readily destructively affected by 
the developed toxins. Possibly there is erected a protective barrier, 
which is efficient against so virile an organism, by the leucocytes, 
those active motile guards which swarm into the circulation as de- 
fenders of our bodies when its integrity is threatened by the in- 
vading foe. If such cases have been submitted to treatment we 



ical examina- 
tion 



INFECTIOUS DISEASES 41 

should hesitate before attributing the happy result to the thera- 
peutic measures which may have been employed. 

Returning now to the patient: Seize the first opportunity to 
obtain specimens of the blood and urine, for examination. The 
blood should be examined daily, or oftener, including an enumera- 
tion of the red and white corpuscles and a differential leucocyte 
count. Wright's (or similar) stain you will find most satisfactory. 
With painstaking search pneumococci may be detected in the 
preparation. Cultures should be made early, and repeated when- 
ever special information is required as to the characteristics of the 
pneumococci. The blood should be obtained from a vein at the 
bend of the elbow ; the skin should be scrupulously cleansed and the 
needle and the Leur syringe perfectly sterilized. Three to five 
cc. of blood to 100 or 150 cc. of plain or glucose bouillon is a desir- 
able proportion. With every opportunity, and in special cases the Scheme of crit- 
opportunity should be made, the serum should be examined for 
urea. Whenever hemoglobin appears in the urine the serum of the 
blood should be examined for hemoglobin. The daily examination 
of the urine should include, especially, the quantity in twenty- 
four hours, total solids, total urea, total chlorides, total sulphates, 
proportion of phosphates, proportion of indican, and casts. 

The pneumococcal toxin must be one of extraordinary virulency. 
We have all marveled at the profound impression made upon the 
patient's system by the introduction into the nutritional fluids of 
the body of an infinitesimal quantity of the pneumococcal toxins, 
and these diluted beyond computation, as evidenced by the profound 
chill, raging fever, complete prostration and other equally notable 
phenomena. Among the latter the first to attract attention is the 
remarkable reduction of the arterial tension, which is one of the 
earliest and most persistent of the symptoms of the disease. This 
is probably an efficient provision of Nature for mobilizing the re- 
serve army of leucocytes into the circulatory current, and for the 
purpose of retarding the passage from the blood into the extra- 
vascular serum of the pneumococcal toxins, developed in the blood 
or introduced into this liquid through the lymphatics which drain 
the inflamed pulmonary area, thus protecting the tissue cells from 
the irritating and paralyzing effects of these deleterious substances. 

Certain other consequences of this capillary paresis may be 
noted. The blood with each ventricular systole is directly pro- 
jected through the capillaries into the veins; the venous system 
becomes overfilled while the arteries become correspondingly de- 
pleted; capillary osmosis is greatly reduced and the extra-vascular 
serum becomes more or less stagnant; the tissue cells lack their 
accustomed stimulus, are insufficiently nourished and are constant- 
ly bathed in a solution of their own waste; later, with returning 



42 



INFECTIOUS DISEASES 



Veratrum 
viride 



Venesection 



vascular tone, those waste materials will enter the general circula- 
tion. It should be here noted that as the malady progresses, with 
rapid multiplication of bacteria and greatly increased production 
of toxins, the effects above noted are not correspondingly intensi- 
fied. This may be due to a variety of causes, as, e. g., temporary 
paresis of the hypothetical sensitive horns of the nerve cells; sim- 
ple accommodation to an irritant; intra-vascular retention of 
toxins; dilution, or deterioration, of those held extra -vascularly ; 
their absorption by protecting cellular elements; their neutraliza- 
tion by leucocyte secretions. 

Under these circumstances what shall we do ? Shall we assume 
that Nature is right, but incompetent, and, following her lead, at- 
tempt to further facilitate the escape of the blood through the 
capillaries by the administration of such agents as nitroglycerine, 
nitrite of sodium, iodide of potassium, veratrum viride, etc. ? Shall 
we presume that Nature is mistaken and attempt to correct her er- 
ror by having prompt recourse to adrenalin, digitalis, etc.? Shall 
we assume that Nature is correct in theory and practice, or shall 
we acknowledge our ignorance in the premises, and in either case 
forbear active interference? These are questions of great impor- 
tance. Practically I am inclined, in the ordinary case, to supple- 
ment the evident efforts of Nature by giving, during the first few 
hours only, two or three drops of fluid extract of veratrum viride 
every one to three hours until slight nausea has been induced, 
or the initiatory surprise of the attack has passed. 

This remedy, a variety of which was used by Gessner in the VI. 
century, was brought into considerable prominence by Norwood and 
other American physicians in the second third of the last century. In 
pneumonia it quiets and retards the excited and rapid heart, while in- 
creasing the volume of blood forced through the arteries without in- 
creasing the peripheral tension. If the tincture is used it should be 
noted that the last revision of the U. S. pharmacopoeia has reduced the 
strength seventy-five per cent. 

Aconite, iodide of potassium, nitro-glycerine and other agents hav- 
ing similar actions offer no advantages over veratrum viride. 

In those cases with increasing nervous perturbation, exalted 
temperature, circulatory excitement, cerebral and general conges- 
tion and thoracic oppresison during the first or second day, mod- 
erate or free bleeding — twelve to twenty-four ounces — should be 
practised. By this procedure the pneumococci and their toxins are 
immediately reduced by a moderate or considerable proportion. If 
now liquids are largely introduced into the circulation, by the 
mouth, by the rectum, or by hypodermoclysis, the remaining mor- 
bid matters are further diluted. Blood-letting at this time gives 
great and speedy relief, apparently bridging over a period of stress 
until the system, in the ordinary course of events, accommodates 
itself to the pathological burden. This procedure I have prac- 



INFECTIOUS DISEASES 43 

tised a great many times under these circumstances and always 
with satisfaction; never with regret. Venesection is not required 
in every case; the patient should be selected most carefully; like- 
wise the conditions and the time. You should not bleed the very 
young, the very old, the anemic nor the weak. 

One hundred and sixty-seven years ago Cleghorn observed that Temperature 
which holds true to-day, namely, that in pneumonia "the tempera- 
ture rises, in the afternoon, to the 102d, and in severe cases to the 
104th, degree of the Fahrenheit scale." There can be no doubt that, 
as a rule, high corporeal temperature marks the severe case, but it 
does not necessarily follow that the exalted temperature is in itself 
detrimental and should be directly reduced. Nevertheless I am 
quite sure that, generally, patients who have much fever are rend- 
ered more comfortable by some of the measures which may be em- 
ployed with an antipyretic effect, and I therefore recommend their 
use. 

Of the legion of antipyretic measures I may mention the fol- Heat reducing 
lowing as most worthy of confidence: The ice cap, or cold water 
coil, more or less persistently applied. The cold water coil ap- 
plied to the chest or abdomen; surrounding the patient, not too 
closely, with bottles of cold water. Sponging with cool water; 
sponging with warm ; or hot water, followed by a cloth dampened 
with alcohol, with more or less exposure to the air, still or in mo- 
tion, to promote evaporation; these to be repeated more or less 
frequently as required. These measures I have found sufficient in Antipyretics 
the vast majority of cases. Is some cases, during the first, possibly 
the second day, four grains of acetanilid every three hours until 
three or four doses have been given; in addition to reducing the 
temperature moderately will have a happy effect in relieving the 
headache and general aching which are so often present at this 
time ; later it should not be used. The gradually rising high tem- 
perature of the terminal stage can not be safely reduced by any 
means. 

In this connection cold packs, cold baths, aerial refrigeration, 
quinine in large doses, the legion of coal tar preparations, etc., are only- 
mentioned to caution you against their employment as antipyretics. 

The pain of early pneumonia is usually severe and distressing ; Pain 
sometimes agonizing. It gradually subsides and ceases spontane- 
ously within three days. It will be moderately relieved by the 
initial small dose of morphia which I have recommended. During 
the first two or three days we may, with benefit in some cases, ap- 
ply one or two strips of adhesive plaster to the affected side, extend- 
ing the ends somewhat beyond the sternum and spine, so as to limit 
the extraordinary and painful respiratory excursions induced by 
the cough. 



44 



INFECTIOUS DISEASES 



Local meas- 
ures 



Cough 



Inasmuch as the pain may be entirely relieved by morphia, 
and because relief in this manner is recommended by many authors. 
I consider it my duty to enter an emphatic protest against such' 
treatment. Morphia given in sufficient quantity to relieve the pain 
throughout the painful period will obscure the symptomatic field, 
dangerously paralyze the nervous reflexes and induce a false sense 
of security which, I believe, distinctly jeopardizes the patient's life. 
It is true that the minute dose advised may be repeated once or 
twice in the exceptional case, yet in my own practice this is sel- 
dom required. 

The local application of heat often mitigates the pain, and if it 
accomplishes this object it may be used. The same may be said of 
ice bags. 

Leeches, dry or wet cups, sinapisms, stimulating liniments, 
blisters, fomentations, poultices, etc., I do not use. Neither do I 
employ the so-called pneumonia jacket. It may be said of many of 
these local applications that they are simply useless; others are 
harmful. 

During the early days of the attack the cough is usually fre- 
quent and painful; later it may be severe and distressing. For 
the relief of this symptom 1 direct that the temperature and moist- 
ure of the air in the sick room be maintained very equably, and 
that in every way the patient be kept as quiet as possible. The pa- 
tient, by having his attention directed to the fact, and by reason- 
able encouragement, may exercise a very considerable restraint over 
the cough. 

The early small dose of morphia, and the strapping of the af- 
fected side will relieve, somewhat, the cough. Codeine may be 
used with reluctance; I have seen no case in many years in which 
it seemed indicated. Heroin I consider very objectionable. The 
same may be said of Dover's powder and other deceiving prepara- 
tions of opium. Terpine hydrate has been reputed useful; I have 
used it many times without having observed beneficial results. In- 
halations of chloroform have had their day. The bromides, and 
sedatives generally, are to be condemned. Should I encounter a 
case requiring a cough-restraining remedy my choice would be in 
favor of minute — one thirtieth grain — doses of morphia, with a 
drop of chloroform, in a pleasant syrup ; such cases, I am sure, are 
very rarely encountered. 

The so-called expectorants^ of which iodide of potassium is 
probably the only one of real efficiency, I do not employ. 

The questions which I have presented are those which will de- 
mand consideration, and decision, very early in the attack, but 
others arise with surprising promptitude. For example: after the 
initial nervous shock has been relieved the veratrum viride should 



INFECTIOUS DISEASES 45 

be discontinued, with the question of interference, or non-inter- 
ference, in the circulatory disturbance again before you for consid- 
eration. My own practice is to now give small doses — one-half to Circulatory 
one drachm — of a reliable infusion of digitalis every four to six 
hours. Later, with any evidences of further vaso-motor paresis, 
the dose is increased and the interval, possibly, shortened. The ob- 
ject being to keep the arterioles and capillaries stimulated to mod- 
erate contraction, and the dosage and frequency of administration 
modified from time to time as required to produce this effect. 
Valuable as is this drug, I am sure that its beneficent action is 
best displayed in the mid-stages of the attack, and as a preventive 
of the profound circulatory depression which often marks the be- 
ginning of a fatal ending, under which conditions, in my experi- 
ence, it has proven useless. 

Leucocytosis, particularly manifested by a large proportional Leucocytosis 
and absolute increase in the polynuclear cells, appears promptly 
upon the advent of pneumonia, and continues throughout the at- 
tack. The eosinophiles are practically driven out of the peripheral 
circulation, their reappearance coinciding with the earliest decline 
in pathogenic activity. To any one who gives the subject ob- 
serving and reflective consideration it must be evident that leucocy- 
tosis plays an important protective role, although the exact nature 
of this defense may not be known. It is probable, however, that 
these mobile secretory glands discharge their faintly alkaline se- 
cretion into the sanguineous serum, where it acts upon the pneu- 
mococci and pneumotoxins, and finding their way without the ves- 
sels acts in a similar manner upon the extra-vascular toxins. Now 
it is well known that in some cases leucocytosis fails to appear, or 
is slight and inefficient; also that in such cases the death rate is, 
with exceptions, greatly in excess of that pertaining in those ac- 
companied by leucocytosis to the ordinary degree. From these 
facts it is reasonable to conclude that it were best for us to stimu- 
late leucocytosis, if possible, in those cases in which it is deficient. 
This may be accomplished, without risk, by the use of nucleinic 
acid, and there may be given in these cases only, one-half to one 
teaspoonful of a five per cent solution every three to six hours as 
required to produce the desired results. 

As the result of some desultory observations which I have made Oxygen 
during the past five or six years I am prepared to say that in many, 
if not in a great majority, of cases in which nucleinic acid is given 
it will be found that the blood platelets will be reduced in number 
and the coagulability of the blood noticeably diminished. Might 
this agent not be properly employed for the purpose of preventing 
the formation of cardiac and vascular thromboses? This I can 
only offer as a suggestion. Because of their known tendency to 



46 



INFECTIOUS DISEASES 



Chloride 
excretion 



Sleeplessness 



increase the proportion of blood platelets, and the coagulability of 
the blood, lime and gelatine should not be used in pneumonia. 

None of the pneumonic phenomena are more remarkable than 
the great diminution, or disappearance, of the chlorides from the 
urine. This is probably due to their being required in the system 
for purposes of defence against the pneumococcal toxins, or the 
pneumococcus itself ; or for the retention of diluting liquids in the 
extra-vascular spaces and in the tissue cells. Should we empha- 
size these efforts of Nature and systematically use sodium chloride 
as a therapeutic agent? This I answer affirmatively, and advise you 
to give it with such freedom, by mouth, by rectum, or hypoder- 
mically, that it will not disappear from the urine. Personally I 
prefer to find a moderate amount of chlorides in such urines. 

At this time, before it is required, have on hand a supply of 
oxygen. It will probably not be needed early, but it is so useful at 
the very beginning of respiratory embarrassment due to defective 
aeration, and its employment is so likely to be then neglected, if not 
at hand, that I consider this preparation of prime importance. You 
are now ready to make use of this agent, freely and frequently, at 
the very beginning of that slight but steadily progressive increase 
in frequency and shallowness of breathing which when observed 
by the experienced practitioner fills him with well-founded appre- 
hension. When once begun oxygen will probably be required until 
convalescence has been declared. 

The measures which have been mentioned will be found applic- 
able, with modifications, to the ordinary case during the first two or 
three days of the attack. Beyond this, adaptations, deletions and 
additions may be required; certainly the physician should sharpen 
his wits and redouble his watchfulness in order that he may an- 
ticipate, and not simply recognize, the earliest manifestations of 
those portentous conditions which often appear with such remark- 
able celerity. For example : — 

In some cases early disturbed sleep may become marked in- 
somnia, usually with an unimpaired, or even sharpened intellect 
— an ominous symptom indicating profound toxemia. To suc- 
cessfully combat this condition will tax to the full one's thera- 
peutic resources. My own practice is to, early or in anticipa- 
tion, give a saline cathartic, the action of which may be expedited 
by a stimulating enema; follow with a minute, or small, dose of 
morphia, hypodermically, and one or two cups of coffee; later 
give one ounce of kummel and ten grains of trional, and an addi- 
tional half ounce of kummel and five grains of trional if not asleep 
in an hour. 

In these cases you will often find evidences of intestinal putre- 
faction, and for this reason there should be given, in addition 



INFECTIOUS DISEASES 47 

to the saline ? some intestinal antiseptic, as, e. g., salol in small 
doses. In some of these cases, happily rare, there occurs, late, 
an uncontrollable, fetid diarrhea, which may become involuntary 
and usually ends with the patient's death. The sudden onset 
of this diarrhea, is often unexpected, although it is only the cul- Gastro-Intesti- 
mination of an intestinal sepsis which could have been readily de- 
tected, and probably corrected, if it had been looked for. In my 
opinion no case of pneumonia is properly managed in which care- 
ful and frequent investigations of the functional activity of the 
gastro-intestinal canal are not made. In these cases the urinary 
sulphates, and indican, are always increased, sometimes to an enor- 
mous extent. Prophylactic management should be the rule; when 
recognized energetic treatment should be promptly instituted. 

In another class of cases there occurs, after the height of the Delirium \\ 
attack has been reached, a delirium which gradually increases in 
intensity, which also depends upon toxemia, although it is quite 
clear that the character of the toxemia is fundamentally different 
in the two classes of cases ; the management should be much the 
same. In these cases of delirium I have had excellent results from 
free bleeding, followed by normal salt solution by the mouth — in 
the form of weak broths — by the rectum, or by hypodermoclysis. 

The victim of chronic alcoholism who harbors the pneu- Alcoholism 
mococcus in his upper respiratory tract is frequently attacked by * nd delirium 
pneumonia. Such patients often have, early, that peculiar form 
of delirium known as delirium tremens. This condition^ in pneu- 
monia, is one of gravity, and demands most considerate care and 
mature judgment. The patient should be constantly watched, be- 
cause he almost always imagines he is beset and pursued by immi- 
nent dangers and cunning enemies and he often seizes the first 
opportunity to escape. He will usually require restraint, and this 
may be given by the nurse in some cases; in others he may be re- 
strained by securely fastening the bed coverings to the sides of 
the mattress; in some others mechanical restraint will be found 
necessary, and is the most humane. Digitalis, in large doses, I al- 
ways use. To procure sleep, chloral, carefully administered, is 
probably the safest hypnotic. My practice is to give fifteen grains 
the first dose, followed by seven and one-half grains every half hour 
until the patient is asleep. At the same time give one-half to one 
pint of hot milk, and if possible, an enema of one-half to one pint 
of normal salt solution. With evidences of collapse give aromatic 
spirits of ammonia by the mouth, the previously mentioned cam- 
phor solution by deep injection, strychnia and one or two minute 
doses of morphia hypodermically. 

In some cases, late, there gradually — rarely suddenly — develops Intestinal 
an intestinal paresis, with abdominal distention and inability to paresis 



48 



INFECTIOUS DISEASES 



Pulmonary 
edema 



Cardiac failure 



pass flatus. This denotes a very dangerous, but not necessarily 
hopeless, state. In such cases you should be alert in your obser- 
vations and ready in the application of proper remedies. Give 
the stimulating enema of glycerine, sulphate of magnesium and 
water heretofore advised, and make use of the rectal tube as often 
as required to stimulate intestinal peristalsis and relieve the canal 
from accumulated gases. Give one- twentieth to one-thirtieth grain 
of strychnia, hypodermicaliy, every two to four hours; give digi- 
talis and caffeine in large doses, provided they can be absorbed; 
give by deep injection, a hypodermic syringeful of the camphor 
solution which you have already had on hand for such an emer- 
gency; early it will be well to bleed and to do a hypodermoclysis. 

Pulmonary edema is an occasional event which, notwithstand- 
ing its very serious nature, may appear early enough to permit of 
prompt relief. Let me ask you to recognize it promptly. At the 
very beginning raise the foot of the bed as heretofore directed, in 
order that the serum may flow, uninterruptedly, out of the bronchi 
and alveoli; give one-twelfth grain morphia, one one-hundred-and- 
flftieth grain atropia and one-thirtieth grain strychnia, hypo- 
dermicaliy ; give the stimulating enema. Eepeat, with proper modi- 
fications, as required. Energetic stimulation of the capillaries and 
arterioles by frequent hypodermics of 3 to 5 drops of adrenalin, in 
1 to 10,000 solution may be required. 

Late the appearance of profuse, probably cool, perspiration is 
an ominous, but not altogether hopeless, symptom. The condition 
is probably akin to that of pulmonary edema and requires a prompt 
appeal to a similar line of management. 

Cardiac failure, which is not a simple but is a highly compound 
and complex condition, is the marked feature of nearly all fatal 
cases. The foundation for this unfortunate condition is laid at 
the very beginning of the attack, the entering wedge being the vaso- 
motor paresis which speedily transfers a great excess of blood from 
the arterial to the venous side of the circulatory tree. The immedi- 
ate consequence is a loss of cardiac balance, the heart contracting 
forcibly against an increased resistance on the one side, and a di- 
minished resistance upon the other. It is probable that, in the 
latter of these, it is the endless overreaching, so tiresome to any 
muscle, which is most detrimental. This loss of equilibrium, and 
its consequences, steadily increases in degree until in many, if not 
the majority, of cases it becomes grave, and in a very large pro- 
portion acute — and deadly. To the physician ? and to the patient 
if he were aware of the fact, the most hopeful feature in these 
cases is the assurance that if the state of danger can be carried 
along a short time the period of stress may be tided over, with 
timely and spontaneous relief appearing at the crisis — convalescence 



INFECTIOUS DISEASES 49 

following. I am quite sure that one of the questions which the con- 
scientious and observing physician oftenest asks himself is, What 
can I do to minimize and relieve this deplorable condition? I will 
advise that you keep constantly in mind the contingencies along 
these lines and be keenly alert in the detection of early evidences 
of serious circulatory embarrassment. From an early period make 
use of the measures heretofore advised for the purpose of washing 
the blood; remove some of the toxins and dilute the remainder; 
stimulate the nervous reflexes with 1/30 grain doses of strychnia, 
hypodermically, thereby keying up the capillaries and arterioles. 
In the presence of a late acute condition of this kind all these 
measures should be applied with redoubled earnestness; at this 
time we may find that the removal of from twelve to twenty ounces 
of blood will turn the scale toward safety and recovery. 

Let us now shortly consider some of the more important compli- Complications 
cations which may arise during an attack of pneumonia. Pleurisy 
with serous effusion rarely demands active treatment; when it 
does the liquid should be withdrawn, under the strictest aseptic pre- 
cautions. Do not be disappointed, however, if the effusion quickly 
reappears, for this it usually does, until after the lapse of several 
weeks, when it disappears spontaneously. Purulent effusion — em- 
pyema — may be an early feature, although it is oftenest recog- 
nized after an initial defervescence, and is often confounded with 
"delayed resolution." In all cases in which defervescence is unduly 
delayed, or in which the fever returns, I am led, by my observations, 
to explore with the utmost thoroughness the pleural cavity and 
the interlobar spaces, employing if necessary the diagnostic aspirat- 
ing syringe under proper antiseptic precautions, for the presence 
of pus. When found, prompt and efficient surgical measures of re- 
lief must be given. 

Pericarditis with embarrassing effusion should be promptly dis- 
covered and relieved by aspiration^ with later incision and drainage 
if required. Endocarditis, usually ulcerative, occurs sufficiently 
often to be carefully looked for in all cases. Unfortunately it is 
not always detectable; but in any case with prolonged and undue 
weakness, possibly with slight and irregular fever, the question 
should be given especial consideration; if any doubt exists as to 
the diagnosis you should act as if it were clearly present. When 
detected the patient should be kept in bed, in the recumbent pos- 
ture and with absolute rest, for at least six weeks. The rest should 
be so profound that the patient should make no voluntary move- 
ments — not even turning in bed, raising his head, etc. 

Arthritis, suppurative peritonitis, etc., require early — conserva- 
tive — surgical treatment. 

The line between impending and beginning death is an indis- 



50 INFECTIOUS DISEASES 

tinct, nevertheless a most important one. Threatened, or impend- 
ing, death may sometimes be averted by the masterly employment 
of the measures heretofore mentioned, and others, but this is prob- 
ably impossible in the case of beginning death. Here, as a rule, 
the respiratory reflexes are weakened in proportion to the danger. 
Now a dyspnea which is readily recognized by the observer^ but 
which is not appreciated by the patient, is of grave augury, and 
when this is accomplished by a rising and falling of the trachea, 
and a non-obtrusive clicking noise with respiration, and which 
returns almost immediately after coughing, the patient has, in 
my experience, invariably died. So far as I am aware this symp- 
tom antedates all others which denote the approach of death. 

On the other hand when, late in the attack, the patient awakens 
from sleep and sneezes,, or yawns, or stretches, his safety is assured. 

In conclusion : — The treatment of pneumonia may be faultlessly 
exemplary; it may be carelessly useless and harmless; it may be 
reprehensibly pernicious. The fundamental principles of proper 
management may be stated, analyzed and formulated, but their ap- 
plication to meet the exigencies and requirements of the individual 
patient is an art which can not be transferred from one physician 
to another. Satisfactory proficiency in this art can be attained only 
by those who add to native capacity a keen perception of pertinent 
facts, close study of the problem and years of observant practice. 
Failure is usually traceable to inherent incapacity, paucity of nec- 
essary knowledge and restricted experience. 



DIPHTHERIA. 

Serum therapy The injection of antitoxic serum has rendered the treatment of 

diphtheria relatively simple. There is scarcely any need, as a rule, 
for the administration of internal medicines, excepting to treat the 
complications and sequela? of diphtheria, and the latter, provided 
antitoxin is given early in the disease and in the proper dosage, are 
exceedingly rare. 

Both the general and the localized phenomena of diphtheria are 
produced by toxins that the diphtheria bacillus forms. Uusually 
the diphtheria germs remain strictly localized at the site of the in- 
fection with the production of necrosis of mucous surfaces and the 
directly underlying tissues. Occasionally, however, diphtheria 
bacilli invade the blood and cause a serious involvement of the 
viscera. Diphtheria frequently becomes complicated by a mixed 
infection, usually with streptococci, but also with other pyogenic 
cocci. 

With the introduction of serum therapy in diphtheria and the 



INFECTIOUS DISEASES 51 

brilliant results that have been obtained, there has been a tendency 
towards relaxation in the ordinary prophylactic measures. This 
laxity is to be condemned and the ordinary rules in regard to isola- 
tion, quarantine and disinfection should be observed, and the upper 
respiratory passages of the patient should be treated persistently 
with antiseptic applications until they are completely free from 
diphtheria bacilli. In addition, diphtheria antitoxin should be used 
without fear as a prophylactic. As a rule 250 units are sufficient, 
although 500 to 1000 units are by all means better. 

The local treatment, that formerly occupied so large a place in 
the management of diphtheria cases^ has become less important and 
intubation and tracheotomy are performed much less frequently 
nowadays than formerly when laryngeal and tracheal diphtheria 
(croup) were common occurrences. 

There is no longer any doubt that diphtheria antitoxin properly 
administered is the best remedy for the disease. Statistics in regard 
to the mortality under antitoxin treatment, and clinical studies in 
regard to the duration and severity of the disease under the influ- 
ence of diphtheria antitoxin, demonstrate this conclusively. Under 
this remedy the course of the disease is, in a large majority of the 
cases, markedly modified, the membrane is loosened and sloughs off 
much earlier, laryngeal and nasal complications are prevented or 
promptly aborted, the general prostration and malaise are not so 
marked, and the temperature does not rise so high and returns to 
normal sooner than if the patient had been treated without 
antitoxin. 

It has been claimed that antitoxin may cause heart failure, Hypothetical 
paralysis, albuminuria, nephritis and other complications. It is antitoxin 
true that cardiac failure and paralysis occur as frequently in 
diphtheria cases that are treated with serum as in cases that are 
treated without serum ; in fact, some statistics show that more cases 
of diphtheria (that survive) develop signs of heart intoxication 
when treated with antitoxin than without; but one is justified in 
assuming that these cases would have died had they not received the 
benefits of antitoxin treatment, so that the figures revealed by the 
statistics in regard to the occurrence of cardiac complications are 
exceedingly misleading and in no sense justify the conclusion that 
the serum produced the phenomena about the heart and the 
peripheral nerves. 

The albuminuria, renal complications, urticaria, arthritis, etc., 
that sometimes follow the administration of antitoxin are due to the 
injection of large quantities of a foreign serum and not to the anti- 
toxin itself ; this is borne out by the fact that nowadays when small 
quantities of concentrated serum are used instead of the large quan- 
tities of dilute serum that were formerly employed, these sequelae, 



52 



INFECTIOUS DISEASES 



Method of ad- 
ministration 



Dosage 



Local treat- 
ment 



notably, the albuminuria and the skin eruptions, are exceedingly 
rare. 

The injection of antitoxin should be made into the subcuta- 
neous tissues and not into the muscles nor into any of the super- 
ficial cutaneous veins. The best locations for the injection are the 
external surfaces of the thigh, the abdominal parietes and the upper 
pectoral region. Nowadays a sterile syringe of proper size and con- 
struction is furnished with each package of diphtheria antitoxin. If 
the syringe should become broken, or if the antitoxin is purchased 
without the syringe, then a large Pravaz syringe should be care- 
fully sterilized and used for the injection. That the field of opera- 
tion and the hands of the physician should be rendered aseptic by 
thorough scrubbing with soap and water and bathing with 
bichloride solution, alcohol and ether need hardly be emphasized. 

It is difficult to state definitely what the proper therapeutic dose 
should be. Very much will depend upon the individual resisting 
powers of the patient, the virulence of the particular infection and 
the duration of the disorder. The United States Pharmacopeia 
recommends an average dose of 3000 units. Less than 2000 should 
rarely be given and 10,000 or more units may occasionally be neces- 
sary. Harm to the patient has never been known to accrue from 
large doses of a properly prepared serum. In very severe cases 
intravenous injection of diphtheritic serum is a useful method of 
procedure, the effect becoming manifest much sooner by this route 
than when the serum is injected intramuscularly or hypodermically. 
In cases suffering from a mixed infection the effects of diphtheria 
antitoxin are not so apparent, nor are the results so favorable. In 
cases complicated with streptococcus the injection of two sera, that 
is, ant istrepto coccus and diphtheria serum, appears indicated. 

It is important to distinguish between infectious with the 
diphtheria bacillus and the pseudo-diphtheria bacillus, for in the 
latter case the diphtheria antitoxin does not protect. In case of 
doubt (and the bacteriological differentiation between the two is 
not always easy, morphologically, in fact, quite impossible) diph- 
theria antitoxin should always be given, for it can do no harm and 
it may do good. 

The local treatment under antitoxin, as stated above, is very 
simple. Meddlesome spraying and swabbing of the throat is to be 
condemned, especially in children, for the excitement incident to 
the local treatment, and the struggles of the child, are decidedly 
detrimental ; moreover, vigorous swabbing of the affected area is apt 
to produce local trauma and to throw the doors wide open for the 
invasion of septic germs and secondary involvement of various in- 
ternal organs. Vigorous local treatment in the nose is especially to 
be condemned on account of the danger of producing middle ear 



INFECTIOUS DISEASES 53 

infections. Besides, the escharotic effect of strong remedies ap- 
plied directly to the diphtheritic area is apt to aid the absorption of 
the diphtheritic poison. Drugs strong enough to kill diphtheria 
bacilli are very apt to produce medicinal poisoning from the quanti- 
ties of the drugs that are swallowed, or that are absorbed through 
the diphtheritic area. It is doubtful, moreover, whether strong 
germicides like sublimate, carbolic acid, ferric chloride, silver 
nitrate, lactic acid, creolin and others applied locally exercise any 
very strong bactericide effect, for the bacteria are usually protected 
from the action of the drugs by mucus and by lymph and albumin- 
ous fluids that readily coagulate when touched with these different 
remedies; the contact with the germicides, moreover, is really too 
short to be effective. 

Occasionally if there is much fetor, or if many pus germs are Swabs and 
present, the throat may be swabbed or sprayed gently with a two to 
three per cent, solution of chlorate of potash; or with a one to ten 
per cent, solution of iodoform in glycerin; or with a mixture 
of equal parts of peroxide of hydrogen and water (if the latter drug 
is used, the lips, especially in children, should be protected with 
vaselin) ; or insufflations of iodoform mixed with sugar of milk in 
the proportion of one to three ? or with bicarbonate of soda in the 
same proportion, may be employed. The chlorate of potash solution 
mentioned above may also be used as a gargle. A very popular solu- 
tion for local application is Loeffler's, consisting of : 

Menthol, 10 gm. 

Toluol, 36 cc. 

Alcohol, 60 cc. 

Liq. ferri sesq., 4 cc. 

Best of all are irrigations of the throat every two or three hours Irrigation of 
with copious quantities of a one to two per cent, boric acid solution, nose and mouth 
or with a one-half to two pro mille salicylic acid solution. The 
child's head should be held forward over a bowl and from one to 
two quarts of the solutions allowed to run into the mouth from an 
irrigator hanging four to six feet above the child's head; if there 
is little membrane in the mouth, then the irrigation may be per- 
formed through the nose, although this procedure is not without 
danger on account of the risk of producing middle ear involvement. 

Cold applied either externally or internally is generally very Cold app ii ca . 
grateful and aids in allaying congestion and inflammation. The tions 
patients may either swallow ice pills at frequent intervals or may 
suck ice-cold beverages in small quantities through a straw. Exter- 



54 



INFECTIOUS DISEASES 



Drugs by 
mouth and 
unction 



m- 



Hydrotherapy 



Collapse 



Rest 



Diet 



Croup 



nally, a Leiter coil (see index) is of the greatest benefit, or a 
permanent ice poultice may be used to advantage. 

Internally medicines are not indicated. Antipyretics especially 
are unnecessary and usually dangerous to the heart. In some clinics 
the use of mercury or of silver administered by inunction is popular 
and sufficiently favorable results are reported from this practice, 
especially before the antitoxin treatment was universally employed, 
to warrant the occasional use of this method, either as an adjuvant 
to the antitoxin treatment or as a substitute for it if antitoxin can- 
not be readily procured. 

From fifteen to thirty grains (1 to 2 gm.) of unguentum 
hydrargyri are rubbed into the skin in different parts of the body 
each day, or fifteen to forty-five grains of the unguentum Crede are 
administered in the same way by inunction. The dose of either 
ointment may be increased somewhat on the third or fourth day. 
Inunctions should not be made about the skin of the neck, but in 
other parts of the body. 

Hydrotherapeutic means have a very limited field of employ- 
ment in the treatment of diphtheria. Cold hydrotherapeutic meas- 
ures^ instituted for the purpose of reducing the temperature, are to 
be condemned as superfluous if the diphtheria antitoxin is used, 
and as dangerous, especially to the heart, in any case. If the patient 
goes into collapse from heart failure, then immersion in hot water 
(100°) may be indicated as an emergency procedure. On being 
taken from the hot bath the patient should be wrapped in blankets 
and kept perfectly still in bed for several hours, while analeptics, 
coffee, champagne, whisky, by mouth; ether, camphor, ammonia, 
caffein, hypodermically, may be used. Inasmuch as heart failure is 
apt to occur at almost any time during the course of diphtheria, and 
especially during the convalescent period, analeptic remedies should 
always be kept at hand for emergencies and the attendants in- 
structed in their use. 

A diphtheria patient should be kept at rest in bed and should 
not be allowed to make any sudden movements or to get up at all 
until the temperature is perfectly normal. The heart should be 
inspected daily and, if necessary, supported with a little wine or 
champagne. The diet should be very nourishing, contain an 
abundance of albuminous food and should be palatable. If the 
patient has much difficulty in swallowing it may become necessary 
to administer food either by the rectal route, the stomach tube or a 
nasal catheter. 

Croup, since the introduction of antitoxin, is a rare complica- 
tion. If the membrane forms in the larynx or the trachea, then in- 
halations of equal parts of lime water and distilled water through a 
steam inhaler are usually very grateful to the patient and aid con- 



INFECTIOUS DISEASES 55 

siderably in loosening the membrane. Profuse sweating produced 
b) T pilocarpine hydrochloride one-twentieth to one-half grain (0.003 
to 0.3 gm), hypodermically; by hot, wet packs; by the steam tent 
(see index) or by hot air, are considered efficacious in relieving the 
dyspnea and in promoting loosening of the membrane. 

In nearly all cases the administration of antitoxin acts with par- 
ticular efficacy in promoting shedding of the membrane. The 
expulsion of the membrane may further be facilitated by the use of 
emetics, apomorphine, ipecac, tartar emetic. 

If despite the administration of antitoxin and the employment Intubation 
of steam inhalations, sweating and emetics the membrane continues 
to form or is not loosened and expelled, then intubation or even 
tracheotomy may have to be performed. Fortunately the necessity 
for this operation is becoming less and less frequent. The descrip- 
tion of the methods of intubating or tracheotomy does not lie 
within the scope of this book. 

MALARIA. 

The employment of quinine as a specific renders the treatment Quinine a 
of malaria exact and simple. Quinine and its salts are protoplasmic 
poisons. They act more strongly, possibly specifically, upon lower 
forms of life than on the more highly organized cells of the human Mode of action 
body; hence quinine in doses that do no harm to the protoplasm 
proper of the host possesses the power of destroying unicellular 
organisms like malaria parasites that invade it. 

Quinine preparations may be given by mouth, by rectum, hypo- Mode of.ad- 
dermically and intravenously. In the great majority of cases the 
administration by mouth is effective. If much gastric irritation 
develops from the administration of quinine by mouth, or if it is 
desired to obtain a somewhat more rapid effect, the administration 
by rectum in clysma or suppository may be adopted. If a still more 
rapid effect is desired the drug may be given hypodermically; and 
in pernicious forms of malaria, when the patient is in danger of his 
life and an immediate result is desired, quinine may be injected 
into the veins. 

Numerous preparations of quinine have been used. For admin- Preparations 
istration by mouth the hydrochloride of quinine is the best. Quinine £ e g^eiTby 
sulphate is also very useful. The quinine hydrochloride, however, mouth 
contains percentically more quinine than the sulphate, it is also 
more rapidly absorbed, so that twice to three times as much of the . 

sulphate must be given than of the chloride in order to obtain the c hioride and 
same effect. sulphate 

In very nervous subjects and in individuals in whom the admin- 
istration of quinine exercises an irritating effect upon the nervous 
svstem the valerianate or bromide of quinine may be given in place 



56 



INFECTIOUS DISEASES 



Quinine vale- 
rianate and 
bromide 



Euquinine 



Administration 
in capsule and 
solution 



Hypodermic 
method 



Rectal method 



of the chloride or sulphate. It will rarely be necessary to use these 
compounds, however, for if it is desired to secure a valerianate or 
bromide effect it is always simpler and safer to give the two drugs 
separately. This is especially true as quinine in order to be effective 
must be given in large doses, as will be presently shown, and because 
this task is rendered difficult if the drug is given in chemical com- 
bination with substances that cannot safely be administered in large 
quantities. 

A very useful preparation of quinine is euquinine. This remedy 
is particularly useful for administration to children, as it does not 
possess the bitter taste nor most of the toxic properties of quinine 
hydrochloride or sulphate, while it is quite as effective as any of the 
latter preparations. In giving euquinine instead of quinine salts 
about one-and-a-half parts of euquinine should be allowed in place 
of one part quinine. 

Quinine hydrochloride or sulphate is best administered in cap- 
sule or pill form. It is true that in solution the absorption of 
quinine is very much more rapid, but the bitter taste of such solu- 
tions, that is only poorly disguised by the administration of the 
drug in syrups or in watery solution flavored by various volatile oils 
or in coffee, is a serious deterrent to its employment in liquid form. 

For hypodermic use the acid hydrochloride of quinine (quinine 
bimuriate) is the best ; it should be administered in ten to twenty 
grain doses dissolved in about 2 to 3 cc. of water. The neutral 
chloride of quinine is not very soluble in pure water. If the solu- 
tion is prepared with hot water, however, and if a little urea is 
added, the solubility of the quinine chloride is increased and the 
injection is not quite so irritating. 

For rectal use a little opium should be added to the quinine solu- 
tion, as quinine salts are somewhat irritating to the rectal mucosa. 
The solution may either be made with water or with mucilage and 
one of the following two formula? can be utilized for preparing the 
clysma : 



R 



Or 



Quinine hydrochloride, 


2.0 gm. 


Tincture of opium, 


10 drops 


Water, 


100.0 cc. 



Quinine hydrochloride, 


2.5 gm. 


Tincture of opium, 


10 drops 


Mucilage, 


40.0 cc. 



INFECTIOUS DISEASES 57 

For intravenous injections an acid solution of quinine cannot be Intravenous 
used. The solution should be neutral. The best preparation is the 
following, recommended by Bacelli: 

Quinine hydrochloride, 1.0 gm. 

Sodium chloride, 0.075 gm. 

Distilled water, 10.0 cc. 

This solution is to be heated to body temperature and trans- 
fused directly into the veins of the fore-arm, as described in the 
Section on Pernicious Anemia. The injection of such large quan- 
tities of quinine intravenously generally produces severe symptoms 
of intoxication, i. e., a bitter taste in the mouth, dizziness, tinnitus 
aurium, cold sweats, some precordial distress, palpitation and a feel- 
ing of oppression. These symptoms usually disappear promptly in 
from fifteen minutes to half an hour and are usually negligible. If 
the pulse becomes very weak and slow a hypodermic injection of 
ether, or camphor and ether, may be given. 

The treatment of the malarial paroxysms with quinine varies Time to ad- 
somewhat according to the type of malaria. Inasmuch as very large JJ|J^ 1S er qm " 
doses of quinine are apt to produce a variety of disagreeable symp- 
toms, as indicated above, it is desirable to produce the desired effect 
with the smallest quantity of the drug. For this purpose, especially 
in the simple quotidian type of malaria, it is important to admin- 
ister the quinine in one or two relatively small doses at exactly the 
right time rather than indiscriminately throughout the day. 

The rules that should be observed in the treatment of the simple The simple 
intermittent form of malaria are the following: Provided the type^f malaria 
patient has been observed for several days and it is known that the 
type of malaria is of the quotidian variety, or if the blood examina- 
tion reveals this to be the case, then the patient should receive fifteen 
grains of quinine, twice, six and five hours before the time when 
the attack is expected. This therapy sometimes aborts the attack. 
In most cases, however, the administration of quinine on the first 
day does not stop the attack. If administered at the same time and 
in the same way on the second day, the attack is, in the great ma- 
jority of cases, aborted. It is best then to continue the administra- 
tion of thirty grains of quinine for two or three days more in the 
same manner. This is particularly necessary, if a blood examination 
is not made and the type of malaria positively established, for it is 
important to remember that a daily malarial paroxysm may be due 
to three colonies of quartana, so that here it would be necessary to 
administer the dose of quinine for at least four or six days if the 
parasites are to be destroyed in the amebic stage. 



58 



INFECTIOUS DISEASES 



To abort an 

impending 

attack 



No quinine 
during attack 



Quinine treat- 
ment after the 
attack 



Atypic inter- 
mittent type 



Pernicious 
type 



Idiosyncrasy 
against qui- 
nine 



Remedies to 
replace quinine 

Methylene blue 



If the patient is seen for the first time, when the attack is just 
impending, and if the first attack occurring on the preceding day 
was exceedingly severe, so that it is desirable to prevent the occur- 
rence of another attack, then fifteen to forty-five grains (1 to 3 gm.) 
should at once be administered hypodermically. 

If the patient is seen for the first time during an attack, it is 
altogether useless to give quinine in the simple intermittent form of 
malaria. 

If the patient is seen after the attack and if the seizure was very 
severe, and especially if the exact type of the malaria is not known, 
then fifteen to twenty grains (1 to IV2 g m -) of quinine should be 
given at once and the same dose repeated on the next day about five 
or six hours before the time of the expected paroxysm. 

In atypic intermittent types of malaria and in the sub-continu- 
ous pernicious variety no definite rules can be formulated in regard 
to the exact time for administering the quinine. A safe rule is to 
give from ten to fifteen grains (0.6 to 1 gm.) of the drug by mouth 
every four or five hours for several days. It will often be found 
that the type of the disease then changes to the simple intermittent 
variety which should be treated as indicated above. 

If one is dealing with the pernicious type of malaria with severe 
apoplectic symptoms, or an overwhelming intoxication producing 
coma and tetanic convulsions, then quinine in doses of fifteen to 
thirty grains should be given at once and preferably by the intraven- 
ous method, this dose to be repeated every ten or twelve hours on 
several successive days. 

There are some individuals unfortunately possessing a marked 
idiosyncrasy to quinine. They respond to the administration of 
even small doses of the drug with signs of cerebral congestion, dis- 
turbances of the senses of sight, smell and hearing, with nausea and 
vomiting, severe headache, dizziness, maniacal attacks and somnol- 
ency. While no case of death from quinine administered in thera- 
peutic doses has ever been reported it, nevertheless, becomes neces- 
sary in such cases to reluctantly omit the use of the drug and to 
attempt the treatment of malarial paroxysms by some other means. 
Only in the pernicious type should quinine be administered, not- 
withstanding the idiosyncrasy of the patient and the disagreeable 
reaction that follows its exhibition, for here the best and most 
rapidly-acting remedy must, by all means, be given in order to save 
the patient's life, and the personal sensations of the individual can 
therefore in no way be considered. 

Chief among the remedies that can take the place of quinine is 
methylene blue in doses of two to four grains (0.1 to 0.2 gm.), by 
mouth; or hypodermically, in five per cent, solution in drachm 
doses. It colors the urine a greenish blue and occasionally produces 



INFECTIOUS DISEASES 59 

strangury and slight gastrointestinal irritation. The strangury can 
usually be counteracted by the addition of nux muschata to each 
capsule of methylene blue, a convenient formula being the follow- 
ing one : 

Methylene blue, 

Nutmeg, of each, 0.1 gm. 

M. 

S. Five to six such capsules daily. 

Methylene blue probably acts like quinine by its lethal effect Mode of action 
upon the plasmodium of malaria. In order to be effective it should 
be administered in the above dose several times a day for about ten 
days. It can hardly be said to take the place of quinine, although it 
seems to be as effective as quinine in promoting the destruction 
especially of the crescent form of the malarial parasite. 

Another remedy that sometimes acts beneficially in malaria is Eucalyptus 
eucalyptus. This drug may be given either in the form of the fluid 
extract in one drachm doses several times a day or as the alcoholic 
tincture in doses of two to four teaspoonfuls, or as eucalyptol, in 
doses of ten to fifteen minims (0.6 to 1 gm.) in capsule, two or 
three times a day. 

Of other remedies like antipyrin, carbolic acid, acetanilid, Antipyrin 
phenacetin and many more that have at different times been recom- Carbolic acid 
mended for the treatment of malaria, very little need be said. One Acetanilid 
is rarely called upon to consider other drugs than quinine, methy- Phenacetin 
lene blue and eucalyptus, and the efficacy of all the other series of 
remedies is, moreover, exceedingly doubtful. 

Arsenic, however, has a very distinct place in the treatment of Arsenic 
malaria. Arsenic possesses no lethal effect upon the plasmodium, 
hence it is of very little value in the treatment of acute cases. It is 
highly useful, however, in protracted, chronic, sub-acute forms of 
the disease, especially with malarial cachexia. If marked nervous 
disturbances develop in the course of malaria, arsenic is best admin- Dose and ad- 
istered in combination with quinine either in the form of arsenious imnis ra lon 
acid, sodium arseniate or as Fowler's solution by mouth, as described 
on page 156, or ? best of all, hypodermically, as the cacodylate of soda 
in half -grain to one grain doses, in watery solution, once or twice a 
day. There is no advantage in using quinine arseniate, in fact the 
administration of the two remedies separately allows easier regula- 
tion of the dose of each drug (see above). 

One of the most disagreeable and obstinate symptoms of chronic Splenic tumor 
malarial intoxication is a persistent splenic tumor; and an impor- 
tant part of the after-treatment of malaria is the reduction of the 



60 



INFECTIOUS DISEASES 



Injections 



Acupuncture 



Faradization, 
Cold and Heat, 
X-ray 



To prevent 
malaria recur- 
rences 



Role of the 
mosquito 



size of the enlarged spleen. As a rule a continued course of quinine, 
or of eucalyptus, or of arsenic will bring about the desired result. 
If the splenic tumor persists despite the administration of these 
remedies, then the injection of quinine directly into the spleen, or 
even splenectomy, must be considered. The insertion of a hypoder- 
mic needle in the spleen is, however, a precarious procedure. 

From a series of clinical reports that have emanated particularly 
from Italian clinics, it seems that the insertion of the needle, itself, 
without regard to what substance may be injected, exercises the 
same effect that is occasionally observed when quinine or carbolic 
acid, or other remedies, are injected into the spleen substance. 
Hence the insertion of a sterile needle under aseptic precautions 
should answer the same purpose as the injection of any drug into 
the organ. This procedure, however, should be carried out under 
the most careful aseptic precautions and is best relegated to a 
surgeon. 

Faradization of the splenic region and the application of heat 
or cold rarely exercises more than a transitory influence; exposure 
to X-ray is always worthy of a trial. With the reduction of the 
splenic tumor the cachexia frequently improves rapidly, hence every 
effort should be put forward to accomplish this result. 

In order to prevent re-infection with malaria and, generally 
speaking, as a prophylactic measure to be adopted on entering mala- 
rial regions, the administration of five to ten grains of quinine, two 
or three times a day, is to be recommended. 

The role of the mosquito and the means that must be adopted to 
prevent infection from this source are discussed in full in the Sec- 
tion on Yellow Fever. 



Early adminis- 
tration of 
salicylates 



Salicylic acid 
and its deriva- 
tives almost 
a specific 



Large doses 
necessary 



ACUTE ARTICULAR RHEUMATISM— (Rheumatic 

Fever). 

At the onset of the disease with high fever, pain in one or several 
joints, often sore throat (tonsillitis) and the malaise, anorexia, 
furred tongue and other phenomena attributable to the high fever, 
the patients should be put to bed and the administration of salicylic 
acid or salicylate preparations begun at once. 

Salicylic acid and its derivatives must be considered almost a 
specific in most cases of the disease. Its exact mode of action is 
not known. It exercises an influence upon the nerve ends, chiefly 
in the joints, relieving the pain, and it may also probably possess 
some specific antibacterial and antitoxic action. 

In order to be effective large doses of the salicylic preparations 
must be given. It is futile to give five or ten grains, three times a 
day; in order to accomplish the desired result doses of from sixty 



INFECTIOUS DISEASES 61 

to one hundred and twenty grains (4 to 8 gm.) should be admin- Proper dosage 
istered in the course of twenty-four hours for several days in suc- 
cession. The remedy should, therefore, be given continuously dur- 
ing at least the first three days in doses of ten to fifteen grains (0.6 
to 1 gm.) every three or four hours, day and night. 

The choice of the salicylic preparation is frequently difficult to Choice of prep- 
make. Salicylic acid, itself, is said to act somewhat more quickly aratl0n 
than any of the other preparations, but it is decidedly more irritat- 
ing to the stomach than all its congeners. It should, above all 
things, never be given in solution, as it is soluble in water only in 
the proportion of one to five hundred, and as its solution in alcohol 
is so irritating as to preclude its internal administration in this 
form. If salicylic acid is to be given at all it should, therefore, be 
given in the doses mentioned above in capsules or powders, with 
milk. 

Sodium salicylate may be employed either in solution or in Salicylic acid 
powder or capsule in the same dose as salicylic acid; as its taste is 
rather disagreeable it is best, however, not administered in powder 
form. The most agreeable way of dispensing it is in a solution of 
peppermint water with simple syrup. 

Children should receive smaller doses of salicylic acid, or of *?*£■? gc in 
sodium salicylate, than those specified above. Children up to one 
year should not have more than fifteen grains (1 gm.) of either 
salicylic acid or sodium salicylate in the twenty-four hours; chil- 
dren from two to six should not receive more than thirty grains 
(2 gm.) in the twenty-four hours; and children up to twelve not 
more than forty-five or, at the most, sixty grains (3 to 4 gm.) 
each day. 

The best preparation of salicylic acid, the one that is the least Aspirin 
irritating to the stomach, bowel and kidneys, the one that hardly 
produces any of the toxic signs to be presently enumerated, even if 
given in very large doses, is aspirin. It may be given in thirty to 
forty-five grain doses (2 to 3 gm.) two or three times in the twenty- 
four hours; as its taste is not disagreeable it can be dispensed in 
powder form. 

In many cases of acute articular rheumatism in which large Poisoning irom 

salicvlates 
doses of salicylic acid, sodium salicylate or aspirin are given symp- 
toms of poisoning appear within a short time, manifesting them- 
selves by visual disturbances, congestion about the head, buzzing in 
the ears, dizziness, nausea, vomiting. In especially predisposed sub- Idiosyncrasy 
jects having an idiosyncrasy against salicylic acid and its prepara- 
tions, a single dose may produce violent symptoms of intoxication, 
headache, delirium, coma, retardation of the pulse, palpitation and 
drenching sweats. 



62 



INFECTIOUS DISEASES 



Indications for 
stopping sali- 
cylates 



Salol, sali- 
phen, malakin, 
saligenin, sali- 
cin, oil of 
wintergreen 



Percutaneous 
administration 



Contra-indica- 
tions to use of 
salicylates 



Remedies to 
replace sali- 
cylates 

Lactophenin 
Phenacetin 
Antipyrin 
Salipyrin 

Guaiac 

Potassium 
iodide 

Colchicum 



Alkalies 



If these symptoms of intoxication appear one is often forced to 
stop the administration of salicylates and to give other remedies in 
their place. Occasionally only mild toxic symptoms will develop 
after the exhibition of one of the salicylic preparations. If the in- 
toxication is not too severe it is always worth while to try to continue 
the salicylic therapy by using some other derivative of salicylic acid, 
as salol (not in nephritis), saliphen, malakin, saligenin, salicin or 
oil of wintergreen, especially the latter in doses of twenty drops 
every two or three hours in milk or in capsule. 

The exhibition of salicylates by the percutaneous method, i. e., 
by means of ointments rubbed into the skin, is also a very useful 
mode of administration and one that can to advantage be combined 
with the administration of salicylates by mouth. In cases in which 
the symptoms of gastric irritation appear without any of the other 
signs of salicylic poisoning, the method of administering the drug 
by inunction alone is often efficacious. Here ointments made of one 
part of salicylic acid to ten parts of lanolin, or of equal parts of oil 
of wintergreen and lanolin, are especially serviceable. 

Aside from the appearance of violent symptoms of intoxication 
in otherwise healthy subjects shortly after the exhibition of salicylic 
acid preparations, there are distinct contra-indications to the use of 
these remedies, namely, cardiac disease, acute renal disease, conges- 
tion about the head and gastritis. 

If the patient is unable to take salicylic acid or its derivatives 
in large doses, then it is futile to continue their administration in 
small doses, and recourse is better had either to certain other reme- 
dies to be now discussed or to local measures alone. 

Eemedies that can in a measure replace the salicylates are, above 
all, certain of the coal-tar preparations, chief among them lacto- 
phenin, which may be given in ten to fifteen grain (0.6 to 1 gm.) 
doses, every four hours; phenacetin in five to ten grain (0.3 to 0.6 
gm.) doses; or antipyrin in five to fifteen grain (0.3 to 1 gm.) 
doses, three or four times a day. A very useful antipyrin prepara- 
tion is salipyrin, a combination of salicylic acid and antipyrin, 
which is used in the same doses as antipyrin. Guaiac, as the car- 
bonate in 5 grain doses several times a day, is again coming into 
use and seems to be of some value. Potassium iodide, colchicum and 
many other remedies that have at different times been recom- 
mended, nowadays no longer occupy a place in the therapeutic 
armamentarium to be employed against rheumatic fever. 

In recurring inflammation of the smaller articulations, enemata 
of colargol are often of use in the strength of 3.0 to 5.0 of colargol 
dissolved in 200 c. c. of water. 

An energetic alkaline therapy instituted from the beginning 
of the disease and continued throughout its course, using alkalies 



INFECTIOUS DISEASES 63 

either alone or in combination with salicylates, is always useful. 
The patient should receive from five to fifteen grains (0.3 to 1 gm.) 
of bicarbonate of soda in a tumblerful of water or milk, four or five 
times a day. As a beverage lemonade or orangeade answers a simi- 
lar purpose, for the citrates contained in lemon or orange juice are 
promptly converted into carbonates in the body. 

Local treatment in acute articular rheumatism is of much less Local treat- 
importance than in chronic forms of articular disease. The chief 
object is to make the patient comfortable and this can best be done 
by arranging the pillows in such a way that cramping and conges- 
tion of the affected joints are avoided, or by applying rests or sup- 
ports according to the requirements of the case. It is rarely neces- Rest of joints 
sary, nor can it be considered good practice, to immobilize the 
affected joints, although, formerly, the adjustment of permanent 
splints, or even of casts, was in vogue. 

Some patients prefer hot applications, others are made more Heat and cold 
comfortable by the application of cold to the joints. Heat applied 
by the hot air bath is usually most soothing, and if the house is 
wired for electricity a box lined with several incandescent globes can 
be placed over the joint several times a day with great relief to the 
sufferer. The thermophore (see index), hot water bags, or poultices 
are often grateful. 

A very effective dressing is the application of absolute alcohol Alcohol dress- 
to the joints. A towel or several layers of gauze are soaked in abso- 
lute alcohol, applied to the affected joint and held in place by a 
loose bandage for eighteen to twenty-four hours. Simply wrapping 
the joint in cotton and bandaging loosely is of considerable benefit. 
Alkaline washes applied by means of cloths wrung out of a warm ten Alkaline 
per cent, solution of soda and covered with flannel and renewed was es 
every few hours are useful. Salicylic ointment and oil of winter- 
green ointment, as described above, can always be applied to the Salicylic oint- 
joint provided there is no idiosyncrasy against salicylic acid men 
poisoning. 

An ointment of the following formula is also sometimes very 
useful : 

Plumb, iodat, 10.0 

Lanolin, 

Vaseline, aa 50.0 

Aside from the application of wet, hot or cold cloths to the Hydrotherapy 
joints other hydrotherapeutic means are of very subordinate im- 
portance in this disorder. General baths, warm or cold, are of no 
benefit, may even do harm, and are, above all, very disagreeable to 



64 



INFECTIOUS DISEASES 



Rest in bed 



Ice-bag to 
cordium 



pre- 



Room hygiene 



Clothing 



Diet 



Treatment of 
convalesence 



patients, because they are thereby forced to move about and de- 
prived of their rest. Cleansing baths are, therefore, best given by 
sponging in bed. 

The element of rest is exceedingly important, especially in view 
of the frequent involvement of the heart. Any sudden exertion, 
getting up quickly, going to the toilet should, therefore, be forbid- 
den. Upon the appearance of signs of endocardiac involvement an 
ice-bag should be intermittently applied to the precordial region 
and the other measures instituted that have been described in full 
in the Section of Acute Endocarditis. 

The temperature of the room should be kept between 60 and 65 
degrees and the patient carefully protected from drafts and cold, 
especially moist air. If the house is moist, then the driest and most 
sunny room should be selected for the patient with rheumatic 
fever. The patient should wear a flannel night-shirt, and sleep 
between blankets that are not too heavy and yet warm enough. In 
many instances the pressure of the blanket upon the affected joint 
is exceedingly trying to the patient. In such cases a suitable sup- 
port should be arranged of wire or wood to protect the joints from 
such pressure. 

The diet should, in the beginning and during the stage of fever, 
consist exclusively of milk. It can conveniently be given in the 
form of the milk-cream mixture (see index). Later when the ap- 
petite returns, the patient may receive other articles of food accord- 
ing to his tastes. While the importance of uric acid in the pro- 
duction of acute articular inflammations is very doubtful no harm 
can, nevertheless, be done by excluding from the bill of fare, dur- 
ing the acute stage of the disease, articles of food containing nu- 
cleins and articles containing extractives (purin bases) ; in other 
words all internal organs, young germinating plants, raw, rare, 
cured, smoked and corned meats, bouillons, meat extracts and gra- 
vies (see also Section on Uric Acid Diathesis). 

It is very important that sufferers from acute articular rheur 
matism should not get up too soon, as there is always a tendency 
to recurrences in this disorder. Sometimes the fever will become 
elevated several degrees during the stage of convalescence without 
any articular manifestations. In such cases the administration of 
ten to fifteen grains (0.7 to 1 gm.) of salicylate of soda, or of as- 
pirin, three or four times a day, for two or three days, is a useful 
measure to reduce the temperature and to prevent recurrence of 
articular troubles. In any event the patient should take small doses 
of salicylates, i. e., five to ten grains of sodium salicylate, or of as- 
pirin, for several weeks after the fever has disappeared and all the 
articular manifestations have receded.* 



*For "antibacterial treatment" see page 108. 



INFECTIOUS DISEASES 65 



TETANUS. 



Tetanus complicated with infection by pus-producing organisms 
is more serious and more difficult to combat than uncomplicated 
tetanus. In cultures the virulence of the tetanus bacillus seems 
to be increased by the presence of certain staphylococcic organisms 
and pus-forming cocci. In the site of infection the leucocytes be- 
come occupied in combating these germs and the destruction of the 
tetanus bacillus is thereby largely prevented; furthermore certain 
saprophytes by consuming the oxygen about the site of the infec- 
tion favor the development of anaerobic conditions that are so suit- 
able for the development of the tetanus bacillus. 

The tetanus bacillus exercises its deleterious effects by the dis- 
tribution through the organism of soluble toxins, the one, tetano- 
spasmin, produces typical nervous phenomena, the other, tetanoly- 
sin, produces myelitic phenomena. Both poisons are carried to the 
nerve tissue by way of the lymphatics. Occasionally, particularly in 
mixed infections, tetanus bacilli are carried into the circulation, 
but this is a rare event. 

Tetanus antitoxin may be considered a specific prophylactic Tetanue anti- 
against tetanus. Given within a few hours after the premonitory prophylactic 01 ° 
signs of tetanus have made their appearance the remedy is oc- 
casionally efficacious. In fully developed tetanus, antitoxin is Effects in de- 
probably without value. It is very difficult to render conservative tanU g 
judgment in regard to the curative virtue of tetanus antitoxin in 
those instances of tetanus that run a protracted course and finally 
recover, because a considerable number of cases of tetanus progress 
towards spontaneous recovery without the administration of the 
antitoxin. The great majority of tetanus sufferers, however, that 
receive antitoxin in later stages of the disease succumb neverthe- 
less. Notwithstanding this ambiguous and largely negative evi- 
dence in regard to the efficacy of tetanus antitoxin in fully de- 
veloped tetanus the remedy should be given a trial, for no harm can 
ever accrue from its administration, and it is possible that here 
and there an isolated case may be benefited by it. 

It appears that tetanus antitoxin possesses the power of neutral- Mode of action 
izing tetanus toxin while it is still circulating and before it has be- 
come permanently attached, so to say, to the ganglion cells of the 
central nervous system ; when this attachment has occurred the rem- 
edy is apparently without effect. This postulate would explain the 
value of the remedy as a prophylactic and its modifying influence 
upon the course of the disease if administered within twenty-four 
to thirty hours after the first signs of irritation of the cerebrospinal 
axis have made their appearance, and its inefficacy in most cases 
if administered later in the disease. 



66 



INFECTIOUS DISEASES 



Indications 
for use of te- 
tanus antitoxin 



Technique 



Place of in- 
jection 



Administration 
hypodermi- 
cally by lum- 
bar puncture 



By the intra- 
cerebral 
method 



Tetanus antitoxin should, therefore, be used as a prophylactic 
measure in every case of trauma in which the wound is contam- 
inated with dirt, especially manure, and particularly if dirt or 
manure particles have been carried deep into the tissues where they 
are deposited in a location that is protected from the air; for the 
tetanus bacterium leads an anaerobic existence and nourishes best 
in the absence of oxygen. For this reason punctured wounds pro- 
duced, for instance, by stepping upon a rusty, dirty nail, and 
wounds produced by explosions which send dirt particles deep into 
the tissues, as in Fourth of July injuries, are especially liable to 
be followed by tetanus. 

In order to develop its maximum efficiency, as a prophylactic, 
it should be given in two injections, one at the time of the injury 
and the second one in about a week — or oftener. It appears that 
there is very little hope of cure from the subcutaneous use of tetanus 
antitoxin, if the symptoms of the disease have existed for more than 
thirty hours, and in these cases the intravascular method of injec- 
tion should be employed. Even in such cases, however, very little 
more can be expected of the antitoxin than to neutralize the toxin 
that may be still circulating and that has not yet reached the end 
organs of the motor nerves but is still engaged in its passage 
through the ganglionic axis cylinders. It is possible that some of 
the toxin that has already been bound to the ganglionic cells may be 
torn from its new connections by sufficiently large and active doses 
of tetanus antitoxin, but this effect seems rather problematical. 

Tetanus antitoxin is best administered near the place of infec- 
tion. If the injury is about the head, or in other regions of the 
body where it is difficult to inject large quantities of fluid under 
the skin, then at least a portion of the antitoxin should be injected 
near the seat of the injury and the rest in some other part of the 
body. 

The best method of administering tetanus antitoxin is by hypo- 
dermic injection. The administration by lumbar puncture is also 
very useful, provided . it is carried out under aseptic precautions ; 
for the antitoxin is more rapidly absorbed from the subarachnoid 
space than from the subcutaneous layers of the skin and, more- 
over, diffuses more rapidly through the cerebro -spinal fluid than 
through the blood. 

In extreme cases recourse must be had to surgical adjuvants, 
namely, exposure of the largest nerve trunk near the infected area 
and infiltration of this nerve with antitoxin, or even injection of 
the antitoxin directly into the spinal cord near the medullary cen- 
ters. The injection into the nerve trunk should be repeated every 
day for a number of days in succession, 5 to 15 drops being in- 
jected into the nerve directly. Intracerebral injections, requiring 



INFECTIOUS DISEASES 67 

trephining of the skull, may be indicated as a last resort. In ad- 
dition to these methods the ordinary subcutaneous or intravascular 
injections should be continued and persistent infiltration of the 
wound and the immediately adjacent tissues with antitoxin should 
be practised. 

The intravenous method of exhibiting tetanus antitoxin is not Intravenous 
without danger and serious accidents have been reported from this 
practice. Moreover, it possesses no particular advantages over the 
subcutaneous method of administration by lumbar puncture, for 
the effect produced is only slightly more rapid. 

At least one hundred antitoxin units, and not more than two Number of an- 
hundred units, should be injected during the first twenty-four be injected S t0 
hours. (Behring.) Injections of one hundred units should be re- 
peated on several successive days. An antitoxic unit is that amount 
of tetanus antitoxin that can neutralize ten units of tetanus toxin 
in the test tube; and a tetanus toxin unit ("Grift Einheit") is the 
smallest quantity of tetanus toxin that can kill a guinea-pig, weigh- 
ing about 250 gm. in three or four days. 

Tetanus antitoxin is not standardized as it should be. Of the 
American serum at least 10 cc. should be given as a prophylactic 
measure and this dose should be repeated several times. It is im- 
possible to say how often. The dosage must be regulated according 
to the effect. As a rule 10 cc. intravenously at once and 10 cc. 
subcutaneously on several successive days should be sufficient to 
neutralize all the unbound toxin that is still in the circulation. 

Bacelli and his school warmly recommend carbolic acid, ad- Carbolic acid 
ministered hypodermically, as a prophylactic and a cure for tetanus. c ^j?? ermi " 
I have had no personal experience with this mode of treatment, 
but the reports emanating from Italian clinics are so positive and 
so favorable that the method may be mentioned. Bacelli injects on 
the first day, either as a prophylactic or even after the tetanus 
spasms have set in, a two per cent, solution of carbolic acid in 
such amount that about three grains of carbolic acid are injected 
in the twenty-four hours. On successive days the amount of car- 
bolic acid is increased to three or four times this quantity. It is 
claimed that tetanus cases show a great tolerance to carbolic acid 
and that the drug, administered in this way, exercises a beneficial 
effect upon the most distressing symptoms of the disorder and 
materially shortens the course of the disease, producing a cure in 
many cases. 

The local treatment of the wound is of the greatest importance. Local treat- 
The principles that should govern this treatment are to open the m ^ nt , of the 
contused part by wide incisions so that free entrance of air may be 
favored even to the deeper regions. A careful search for dirt par- 
ticles should be made, fistulous tracts should be explored and the 



68 



INFECTIOUS DISEASES 



General man- 
agement 



Rest, protected 
from external 
irritants 



Hot baths 



Diet and mode 
of feeding 



Morphine 



whole area laid wide open. Various antiseptic dressings, carbolic 
acid, salicylic acid, bichloride, etc., may be used according to com- 
mon surgical principles. 

Aside from the specific treatment with antitoxin and the local 
surgical treatment, the general management of the case is of im- 
portance. Most patients with tetanus wear themselves out and die 
as much from the exhaustion produced by the spasms as from any 
specific lethal action of the tetanus poison; for this reason it is of 
paramount importance to preserve the patient's strength by reduc- 
ing the number and the severity of the tetanic convulsions, while, 
at the same time, maintaining the nutrition of the patient to the 
maximum degree. 

An essential element in the treatment, therefore, is to protect 
the patient from all extraneous irritants — noises, light, contact 
with people and excitement of any kind — for in tetanus reflex irri- 
tability is enormously increased and the sufferers react with spasms 
or convulsions to stimuli that would normally not influence them 
at all. 

A tetanus patient should, therefore, be put to bed in a dark 
room and should be left as much as possible to himself. 

Hot bathing, two or three times a day, in water slightly above 
body temperature, is a very useful adjuvant to the treatment. The 
patients can, to advantage, be kept in warm water, half an hour at 
a time, two or three times a day. I have had the impression that 
this treatment reduces the number of spasms and is successful in 
shortening the convulsions, especially if the patients are placed 
into hot water immediately upon the onset of spasmodic symptoms. 

The question of feeding is often a difficult matter, especially if 
trismus is present. If there is much lockjaw, then the patient 
should be fed by rectum, as described in the Section on Gastric 
Ulcer, or, if necessary, through a nasal catheter. A patient with 
tetanus should receive large quantities of fluid, on the supposition 
that possibly the ingestion of much liquid will aid in diluting the 
circulating tetanus poison. Water should, therefore, be adminis- 
tered copiously by mouth and also by high enemata of warm physio- 
logical salt solution, frequently repeated. Immersion in hot water, 
coupled with free water drinking, unquestionably accelerates the 
lymph stream throughout the body and hence materially aids in 
keeping the toxin in circulation and possibly in preventing its at- 
tachment to the ganglion cells of the nervous system. 

Of remedies that can be given morphine occupies the first place 
and it is good practice to keep the patient more or less under the 
influence of morphine throughout the course of the disease. The 
exact dose can hardly be stated. The patient should receive enough 
to control the spasms, so far as that is possible, and keep him quiet. 



INFECTIOUS DISEASES 69 

If morphine fails to control the spasms, then chloral hydrate, Chloral 
given in large doses of fifteen to twenty grains, four to six times 
a day, by mouth or by rectum, should be substituted. Very violent 
spasms occurring despite the administration of morphine or chloral 
hydrate, can usually be controlled by a few whiffs of chloroform. 
If the chest muscles are in a state of rigid tetanic contraction^ then, Chloroform 
of course, it is very difficult for the patient to inhale at all, so that 
here chloroform inhalations cannot be given. In such cases hot 
compresses to the chest often aid in relieving the spasm and enable 
the administration of chloroform. 

Trional, tetronal, europhen, all given in doses of ten to thirty Trional 
grains (0.6 to 2 gm.), three or four times a day are often efficacious. Tetronal 
Tincture of thiosinamin, five to twenty drops (0.3 to 1.2 cc.) ; ot Europhen 
the extract of cannabis indica one : eighth to one-fourth grain (0.08 Thiosinamin 
to 0.06 gm.) or the fluid extract, two to five drops (0.1 to 0.3 cc.) : Cannabis in- 
antipyrin in five to fifteen grain (0.4 to 1 gm.) doses, repeated sev- dica 
era! times a day; bromide of sodium or potassium, finally, given Antipyrin 
alone or in combination with chloral hydrate, by rectum, in large Bromides 
doses of twenty to thirty grains (1.3 to 2 gm.) are the drugs thai 
all merit trial and occasionally aid in controlling the most distress- 
ing symptoms. 



DYSENTERY. 

The term dysentery is employed to designate a number of dis Definition 
orders of different etiology that are all characterized by colic, tenes- 
mus and the evacuation of small stools at frequent intervals, con- 
taining mucus and blood. One can distinguish between an epi- Classification 
demic and an endemic variety. In addition there are sporadic 
cases which are presumably isolated instances of the endemic va- 
riety. 

Epidemic dysentery is also known by the name of catarrhal dys- Catarrhal 

dysentery 
entery and occurs chiefly when general hygienic conditions are 

very bad. Its course is milder and its mortality lower than in the 
endemic form. It is produced by different bacilli that are pre- 
sumably introduced into the body through the drinking water. In Tropical 
the endemic variety, also known as tropical dysentery, certain ame- a ^ lc ysen " 
ba must be incriminated with causing the disease. Here the sub- 
mucous layers of the intestine are usually affected, whereas in the 
catarrhal variety the surfaces of the mucosa show the first changes. 

In addition there are a number of forms of symptomatic dysen- Symptomatic 
tery that are produced by mechanical causes and that are due to a ysen ery 
variety of intoxications. 

The treatment of all forms of dysentery is essentially the same 



70 



INFECTIOUS DISEASES 



No specific 
treatment 

Diet 



Calomel 



Laxatives 



Ipecac 



Astringents 



and largely symptomatic, for we possess no specific treatment in the 
parasitic varieties. 

The diet should be non-irritating to the bowel and should leave 
a small residue. In the acute forms and until the severe colic, 
tenesmus, frequent diarrhea and the fever stop, the diet should be 
largely liquid and consist of milk preferably diluted with lime wa- 
ter, or strained gruels, or meat broths and soups. A very useful 
food is albumen water made by shaking the whites of twenty eggs 
in a pint or two of water, adding some sugar of milk and some 
flavoring extract. This quantity should be taken in divided doses 
in the course of twenty-four hours. In addition, the patients may 
have abundant water or lemonade or dilute wine. 

As soon as the acute symptoms subside a semi-solid diet may be 
permitted. A solid diet, however, should not be given until all 
blood and mucus have disappeared from the feces, and the diarrhea, 
the colic and tenesmus have been altogether relieved. The diet, in 
other words, does not differ materially from that advised in typhoid 
fever or in any other form of acute intestinal catarrh. 

Of medicaments that should be administered by mouth, calomel, 
given in small (one-fourth grain) doses throughout the disease is 
the sovereign remedy. It acts beneficially both on account of its 
laxative and its antiseptic properties. Vegetable laxatives should 
not be given in this disease as they are apt to be too irritating. Small 
doses of castor oil or of olive oil can do no harm. If there is much 
constipation, especially in the beginning, a brisk saline laxative is 
indicated. 

Very popular, especially in the tropical variety of dysentery, is 
ipecac. In the different countries it is given in different ways. The 
most sensible and least harmful method of administering it is the 
one recommended by English physicians in the British colonies; 
viz.: The patient is first given a hypodermic of one-fourth grain 
of morphine, hot turpentine stupes are then applied to the abdomen 
and an hour after the administration of the morphine, one grain of 
the root of ipecac in capsule is given, followed by copious draughts 
of water. This dose is repeated two or three times at one or two 
hour intervals. In this way large quantities of ipecac can be in- 
troduced without producing distressing retching and vomiting. 

In the acute form astringents may be given, chief among them 
tannin. It is best given in the form of tannalbin, in doses of thirty 
to fifty grains a day in divided doses of ten grains each. Naph- 
thalan, preferably in combination with calomel, acts very bene- 
ficially both upon the colic and tenesmus and the character of the 
stools. Kartulis recommends the following prescription : 



INFECTIOUS DISEASES 71 

Naphthalin, 1.0 grn. 

Calomel, 0.5 gm. 

M. : Make ten such powders. 
S. — One powder every two hours. 

In addition to these remedies narcotics,, opium and preferably 
morphine, hypodermically, may have to be given as palliatives to 
relieve particularly distressing symptoms. 

The rectal administration of medicines is especially useful in Rectal medica 
this disease, because in this way the seat of the trouble can be tlon 
best reached. For very violent tenesmus small laudanum-starch 



mata should be given. 




? 




Laudanum. 


10 drops 


Starch, 


1 tablespoonful 


Lukewarm water. 


200 cc. 


Or 




B 




Cocaine, 


1 gm. 


Water. 


250 cc. 



For severe hemorrhage and colic, sulphate of soda is useful: 

Sodium sulphate. . 10 g. 

Water, 250 cc. 

Or a dilute solution of iron perchloride, or ice water alone, in- 
jected in small quantities into the rectum are all effective. 

More valuable than the use of enemata is treatment by entero- Enteroclysis 
clysis, for it promotes cleanliness of the lower intestine and, at the 
same time, enables the application of healing remedies directly to 
the affected lining membrane of the bowel. The ordinary anti- 
septics like carbolic acid, corrosive sublimate or the salicylates are 
too irritating. The same applies to silver nitrate whose astringent 
properties might otherwise be emplo} T ed to the advantage of the 
patient. Other antiseptic remedies are insoluble in water and 
can consequently not be utilized (iodoform, naphthalin, etc.). The 
chief remedies that can be employed advantageously are tannin and 
quinine, the former to be used in half per cent, solution, the latter 
in warm solutions of the strength of 1 to 1,000 to 1 to 5,000. From 
two to three litres of fluid should be used two or three times a day. 



72 



INFECTIOUS DISEASES 



Chronic 
tery 



The irrigating bag should not be elevated very high, as otherwise 
too great pressure may be exercised upon the bowel wall and per- 
foration occur. Ice water enemata often help. 
dysen- In chronic dysentery practically the same remedies are useful. 
Here again warm quinine solutions or solutions of tannin are very 
helpful. Internally, tannalbin, calomel and naphthalin are the 
chief remedies. 



Treatment 
exclusively 
symptomatic 



Antineuralgics 



Aspirin 
Alcohol 

Hydrotherapy 



INFLUENZA. 

The treatment of influenza, owing to the fact that we possess 
no specific remedy, is exclusively symptomatic. Upon the onset 
of the first symptoms, energetic diaphoresis should be stimulated 
by hot baths, hot drinks, quinine, Dover's powder, as described 
in the Section on Acute Bronchitis. An influenza patient, however 
mild the onset of the symptoms, should be placed in bed and kept 
there until the temperature is normal. The diet should be bland 
and non-irritating, in other words, should consist of the ordinary 
fever diet. 

Of remedies the ordinary antineuralgics arc the most useful, for 
they make the patients more comfortable, reduce the severity of all 
the symptoms and, above all, stop the distressing headache, back- 
ache and restlessness. It is always well to inaugurate the treatment 
with a full dose of calomel, followed by a saline laxative. The most 
useful remedy in my hands has been aspirin in combination with 
quinine, of each five grains, to be given every five hours for three 
or four days. Salipyrin and antipyrin are less safe on account of 
their effect upon the heart. Alcohol is always useful. A little 
whisky and water given throughout the course of the disease aid 
materially in counteracting the heart weakness and symptoms of 
nervous depression that so commonly supervene in influenza. 

Hydrotherapeutic means are of subordinate importance in the 
treatment of this disorder, owing to the comparatively short dura- 
tion of the disease. There is no harm in using the above anti- 
pyretic drugs and no advantage is to be gained from attempting 
a reduction of the fever by the more complicated hydro therapeutic 
measures. Symptomatically, hot bathing, in fact, is always more 
useful than cold hydro-therapeutic means and a hot bath given once 
or twice a day, with an ice-bag or cold cloths to the head is often 
helpful. 

The treatment of the complications is synonymous with the 
treatment of the organs affected and will be found discussed in the 
chapters on Digestive, Respiratory and Cardio-vascular Disorders. 



INFECTIOUS DISEASES 73 

PERTUSSIS. 

(By Dr. Frank Spooner Churchill, Chicago.) 

Two principles may be laid down in the management of whoop- Principles 
ing-cough, viz., take every precaution possible to prevent infants 
and children from contracting the disease; when once contracted, 
treat the individual, not the infection. 

Much can be done, in private practice especially, to guard in- Prophylaxis 
fants and young children against contracting pertussis. The pop- 
ular idea that this disease is a trifling affair, that "they have all got 
to have it and the sooner they have it the better," is fortunately dis- 
appearing. Intelligent mothers now try in every way to prevent 
their children from contracting the disease. They guard them 
rigidly, and properly so, from exposure in this direction. Infants 
and young children should not be allowed to play either indoors 
or outdoors with others who have whooping-cough. Weak, debili- 
tated children, especially those with a tendency to respiratory 
troubles, tubercular or non-tubercular, should not be allowed to 
attend kindergarten or any public gathering of children, both be- 
cause the time thus spent indoors ought to be spent outdoors, and 
because there is great risk of contracting all contagious diseases 
at such gatherings. Nor should they be allowed to play with chil- 
dren who have in any way been exposed to whooping-cough but 
have not yet manifested any signs of the disease themselves. The 
latter may be in the incubative stage of the infection and therefore 
capable of spreading it. 

All children with a suspicious cough, except those who have 
already had pertussis, should be excluded from contact with other 
children. The early diagnosis of whooping-cough is often a diffi- 
cult matter and until one is sure that a hard cough is not a mani- 
festation of this infection, a child with such a cough should be 
withdrawn from association with other children. A high percent- 
age of lymphocytes is strong confirmatory evidence of the disease Lymphocytosis 
and justifies isolation, temporary at least; for it has been shown* 
that in over ninety per cent, of cases of pertussis there is a marked 
lymphocytosis, even in the catarrhal stage before the development 
of characteristic symptoms, and that this lmyphocytosis rarely if 
ever occurs in other respiratory affections accompanied with a 
hard cough. 

We cannot emphasize too strongly the importance of these rigid 
precautions, especially for infants and young, weakly children 
among whom the disease is most severe and so often fatal. They 
should be guarded against it, at least until they are older when it 

♦Churchill, "Journal A. M. A.," 1906, XLVL, 1506. 



74 



INFECTIOUS DISEASES 



General hy- 
giene and diet 



Climate 



Nourishment 



will be a much less serious affair for them. It is of course im- 
possible to observe this great care in the congested districts of our 
large cities, but even here more care can be exercised than is gen- 
erally done. The practice of directing patients with whooping- 
cough to "return" to the clinic cannot be too strongly condemned. 
It is wrong to the other patients, it has a bad moral effect upon the 
students, confirming them in their lay idea that the disease is a 
trifling affair. The physician who practices this custom is crim- 
inally negligent. 

It must be remembered that pertussis is a self-limited disease, 
runs a certain course and that we have no means of cutting it short. 
Obviously then, the indications are to keep the individual in the 
best possible fighting trim that he may have the strength to out- 
last the whooping-cough organism and to sustain the attack with 
as little damage to himself as possible. This is best done by care- 
ful attention to his general hygiene and diet. Medication is a 
matter of secondary importance. 

The patient should have an abundance of fresh air; he should 
be out-doors as much as possible in the daytime and at night should 
sleep in a well-aired, well-ventilated room. He may sleep out-of- 
doors during the spring, summer and autumn months in the north 
temperate zone. In dealing with infants and young, debilitated 
children, however, care and judgment must be used in exposing 
them to the severe winter weather of a northern climate. Large, 
well-ventilated, well-lighted rooms, one for the day and one for 
the night, are undoubtedly better for some of these patients than 
the indiscriminate application of the "fresh-air" treatment. Indi- 
vidual peculiarities must be heeded and the patient treated accord- 
ingly. Those children who live in the congested districts of cities, 
and for whom fresh air, indoors or outdoors, is an impossibility, 
should be sent to a hospital and later to a convalescent home or 
camp in the country. 

A change of locality, as from sea-shore inland or vice-versa, is 
often of benefit, especially where the cough is unduly prolonged. 
The Atlantic seaboard from Cape Cod south is especially desirable 
for such patients. The balmy air and comparatively warm sea 
bathing have a most beneficial effect upon them. Those who can- 
not have this change of environment will be much benefited by 
long hours spent in the parks, at the lake or river front where these 
localities are clean. 

Next in importance to fresh air for older children, and equally 
important with it for infants, is the question of nourishment. 
Those infants fortunate enough to be at the breast should be kept 
there. Those not at the breast should have their diet carefullv 



INFECTIOUS DISEASES 75 

regulated and be put on cow's milk modified to the needs and ca- 
pacity of the individual infant. It is among this class of patients 
that whooping-cough is so serious and so often fatal, as has already 
been said. The disease wears out the baby either by itself or by 
the development of pneumonia or some other complication. Hence 
the maintenance of his nutrition is vital. 

The diet for older children should be largely liquid and easily Character of 
digested. Meals are necessarily irregular; the child is so apt to 
lose a whole meal by a paroxysm coming on soon after eating that 
he must be fed again in a short time. He should remain quiet 
for at least an hour after the hearty meals of the day. Paroxysms 
are apt to come on at evening soon after the child falls asleep, 
possibly due to the recumbent position ; hence it is advisable either 
to give the evening meal earlier or to put him to bed later that di- 
gestion may be further advanced before the paroxysm comes on. 

The bowels should, of course, be kept freely open. Where this L axa tives 
cannot be done by a diet rich in fruits and vegetables, laxatives 
must be used. The fluid extract of cascara sagrada (aromatic) is 
excellent for this purpose; it may be given in doses of ten to thirty 
drops one to three times a day, according to results. Phosphate of 
soda in drachm doses may be given every morning. A thorough 
clearing out of the intestinal canal once or twice a week is often of 
benefit; for this purpose one grain of calomel ? in one dose, or a 
drachm of castor oil may be given in the morning. 

Stimulants must be used in some cases even when no complica- Stimulants and 
tions are present. Brandy is the best form of alcohol to give as it tomcs 
is less likely to upset the stomach than whisky. Strychnine in 
doses of one-one-hundredth of a grain may be given to older chil- 
dren. Iron and cod-liver oil are often indicated in the later stages 
with considerable debility and anemia. 

THE TREATMENT OF THE PAROXYSM. 

There is little to be done when the paroxysm of whooping-cough The paroxysm 
is actually on in older children. Young infants, however, should 
never be left alone during the paroxysmal stage on account of the 
danger of strangulation. They must be taken up during an at- 
tack, held face downward and often it is necessary to clear out the 
mucus from the throat with the finger. A severe paroxysm which 
threatens suffocation may be relieved by inhaling oxygen or ether. 
Intubation has even been done for such. Chloroform should not 
be used on account of the possibly weak condition of the heart so 
frequently present in whooping-cough. 

Medication is of far less importance than the details of general Medication 
treatment insisted upon above. A few drugs, however, do seem to 



76 



INFECTIOUS DISEASES 



Belladonna 



Quinine 



Phenacetine 
and antipyrine 



Bromoform 



diminish the number or severity of the paroxysms and these should 
be tried. They may be given (a) internally, (b) by inhalation, 
(c) -by insufflation. 

(a) Internally. All the drugs in the pharmacopoeia have ap- 
parently been recommended for the treatment of pertussis, but of 
them all only a few have stood the test of time and experience. 
These are belladonna, quinine, phenacetine, antipyrine and bromo- 
form. It is better to delay the use of drugs until the paroxysmal 
stage is well under way ; one preparation at a time should be given 
a thorough trial; if benefit seem to come from its use continue it, 
if not, stop and try another. Some cases are so mild throughout 
that no medicine at all is necessary. 

The effects of this drug must be carefully watched. It should 
be given at first in small doses, one-fourth minim of the fluid ex- 
tract to an infant eighteen or twenty months old, every four hours, 
gradually increasing to one-fourth minim every two hours. Atro- 
pine also may be given in the same way, beginning with about one- 
eight-hundredth grain. Undoubted benefit seems to follow the 
proper use of these preparations in most cases, but they must be 
pushed to the limit, until the flushed face and dilated pupils are 
noticed. The best results are seen in hospital cases which are un- 
der constant supervision. 

This may be given to older children. It should never be given 
to infants. It must be administered in large doses ? ten to fifteen 
grains daily to a child five or six years old. If it disturbs digestion 
it must be stopped. 

These preparations allay the severity and frequency of attacks 
in many instances. They are particularly valuable where much 
sleep is being lost and the child is in an irritable and fretful condi- 
tion. They should be given always with a stimulant, brandy, 
whisky, coffee, caffein, etc. They may be given in fairly large 
doses ; one grain every two to four hours to a six months old infant. 
To an infant eighteen to twenty months old, two grains every two 
hours may be given. For older children larger doses in proportion 
to the age are prescribed. It is recommended by some to combine 
the bromide of sodium with these coal-tar products. I have had no 
personal experience with this method. 

This is one of the more recent preparations. It seems to be 
of value in some cases. It is given in doses of one to three drops 
every two or three hours to an infant two years old, and three to 
five drops every two hours to a five-year-old child. All preparations 
must be shaken before using and it may be given on a lump of 
sugar. 

I have found phenacetine the most satisfactory of the above 
drugs. It has been prescribed always with a stimulant, brandy, to 



INFECTIOUS DISEASES 77 

weak, debilitated or exhausted children, caffein (one quarter grain) 
and sugar of milk (ten grains) to others. 

(b) Inhalation. The administration of drugs by this method 
and by insufflation is based on the theory of the local nature of 
pertussis and aims to allay the irritability of the respiratory mu- 
cous membrane. Inhalation is more effective than insufflation. The 
preparations most commonly used are creosote, cresolene and car- Cresolene 
bolic acid. Cresolene is especially valuable. It is used generally at 

night and may be evaporated on a special lamp or an ordinary croup 
kettle may be used. The windows of the bedroom may or may not 
be kept open, according to the effects produced. The possibility of 
poisoning from these drugs must be remembered and the urine 
watched. 

(c) Insufflation. But little has been accomplished by this 
method and it is seldom used at present. Quinine is most com- 
monly used, mixed with some bland powder (1:10), such as bicar- 
bonate of soda, acacia, talcum or coffee. Antipyrine has also been 
used in this way. 

The local application of cocaine to the larynx is dangerous and 
should not be made. 

The management of the stage of decline in pertussis requires Stage of decline 
but brief mention. The diet can now be increased, more solid food 
being given. Life in the open air should be continued. The 
change of environment in prolonged cases has already been men- 
tioned. But isolation should be continued for at least four weeks 
after the cessation of the paroxysm. The possibility of the develop- 
ment of tuberculosis at this time must be borne in mind. 

The most serious complication of pertussis is broncho-pneu- Complications 
monia. Its management is the same as that of pneumonia from 
other causes, being mainly supportive and stimulating. Eest in 
bed^ an abundance of fresh air, baths, warm or cold, according to 
the child's temperature, his vigor and general condition; as nutri- 
tious a diet as possible and stimulants are the main principles to 
be laid down. Stimulants must be used freely ; brandy and strych- 
nine are the favorite ones ; carbonate of ammonia and nitro-glyc- 
erin are also used. Inhalations of steam, plain or medicated with 
creosote, are of great help and should be freely used. 

While pneumonia is the most frequent complication during the 
winter months, gastro-intestinal trouble is of frequent occurrence 
in infants during the summer weather, and is a serious matter. 
Proper feeding from the outset will do much to prevent its develop- 
ment. Once established, its management is that usually adopted 
under such conditions; emptying and disinfecting the digestive 
tract, modification of the diet, etc. If vomiting is very persistent 



78 



INFECTIOUS DISEASES 



we have to resort to rectal feeding to keep up the patient's nutri- 
tion. 

Convulsions, severe hemorrhages, albuminuria, etc., are to be 
treated according to general principles. 



PAROTITIS. 

(By Dr. Frank Spooner Churchill, Chicago.) 

Hygiene Mumps is generally a mild disease, and but little active treat- 

ment is required. The patient should stay in the house, except 
during warm weather, until the acute symptoms have subsided. 
In the more severe cases, however, accompanied with high tempera- 
ture and general constitutional disturbance, more energetic meas- 
ures must be taken. He should then, of course, be kept in bed. 
Hydrotherapy the bowels kept freely open, baths as in pneumonia or typhoid may 
even be necessary in especially severe cases, and antipyretics may 
also be used. Phenacetine, prescribed as in pertussis, relieves the 
pain and general discomfort. Sweet spirits of nitre is also of value. 
Hot applications to the swollen and tender glands are often ac- 
Drugs ceptable. A mouth-wash should be freely used, and for this pur- 

Diet pose listerine is an excellent preparation. The diet must be liquid 

on account of the pain in swallowing. 
Complications Complications are rare in early childhood. Later, especially 

in early youth, the most serious complication is an orchitis. If 
present the patient must be kept rigidly in bed, the gland being 
supported and hot or cold applications made. He should be kept 
in bed until the acute symptoms have subsided and on getting up a 
suspensory bandage should be worn for several weeks. 

Otitis and nephritis occur but rarely. They should be treated 
on general principles. As in all infections, the urine should be 
examined both during and after the acute stage of the disease. 

Suppuration of the parotid rarely occurs, but if it develop it 
should be treated on surgical principles. 

Children with mumps should be excluded from school and quar- 
antined for three weeks from the beginning of symptoms. 



SCARLET FEVER. 

(By Dr. Wm. L. Baum, Chicago.) 

Prophylaxis I n view of the high mortality during early life and the de- 

creasing susceptibility and danger with advancing years prophy- 
laxis becomes a most important factor. Unfortunately, during the 
incubation period, the contagion may be spread. This is especially 



INFECTIOUS DISEASES 79 

true when a case appears in a family or in a school. The case 
should be isolated at once and the rooms frequented by the patient 
thoroughly disinfected. 

The room occupied by a patient can be disinfected by means 
of formaldehyde, although this method is not so satisfactory and 
thorough as is the washing of the walls and furniture with a 1-2,000 
bichloride of mercury solution, and the boiling of the bed linen, 
clothing, etc. In hospitals^ the formaldehyde disinfection is not so 
satisfactory. At the Cook County Contagious Hospital, where this 
method has been most thoroughly tried, cases of scarlet fever have 
been known to develop in a room subsequently occupied by patients 
suffering from other diseases. This was not the case where the 
bichloride washings were employed. It is needless to say that the 
attendants should be isolated and exercise the greatest precaution 
in their relations to the family and others to prevent the spread of 
the disease. 

Patients should not be allowed to leave the room until free from Isolation 
contagion and until desquamation be complete. Isolation should 
average at least six weeks. The minimum period of exclusion from 
school should be seven weeks. During the week preceding the dis- 
charge, the patient should have at least two baths in a solution of 
sublimate of the strength of 1-5,000. The clothing should be dis- 
infected with steam or by boiling. This is particularly true of 
clothing worn by the patient at the beginning of the attack. In 
one case isolation was carried out for eight weeks and it was thought 
every precaution had been taken. Four weeks after the patient's 
discharge his little brother was sent to the hospital. Five days 
previously the elder brother had, for the first time since discharge, 
worn the suit of clothes which he wore when first attacked, which 
clothes were the only articles that had escaped disinfection. 

Despite the claims made by certain authors and the antique 
use of belladonna, iodide of mercury and oil of eucalyptus as a 
prophylactic, there is no evidence that any medicinal agent will pre- 
vent infection. 

The patient should be placed in a room from which superfluous 
furniture, such as carpets, pictures, etc., has been removed. The 
room should be kept at about 60° F. and well ventilated. There is 
no danger from air currents in the room. Bed coverings should 
be light. 

Care of the mouth, throat and nose is of the greatest impor- Mouth disin- 
tance, since Hektoen has shown that streptococci enter through fectl0n 
the tonsils. For this purpose sodium salicylate in 0.5 to 1.5 solu- 
tion may be given in teaspoonful doses every two hours for the 
first four or five days, as suggested by Fdrchheimer. For a month 



80 INFECTIOUS DISEASES 

wash a solution of boric acid, or one of potassium permanganate 
1-500 can be used. 
Sera Much interest has lately been aroused by the employment of 

antistreptococcic serum. Its value must depend upon the assump- 
tion that the streptococcus is either the etiological factor, or that 
its presence is the cause of the toxic disturbances for whose control 
an antibody is necessary. Various serums have been employed. 
Marmorek's serum, which I have employed in the treatment of 
seventy-one cases, did not reduce the mortality or lessen the compli- 
cations to any appreciable extent. Baginsky, whose early experi- 
ence was of a similar character, later used the serum prepared by 
Aronson, reporting a series of sixty-two cases with a mortality of 
11.3 per cent., while sixty-three cases treated without the serum 
showed a mortality of 17.3 per cent. Escherich, of Vienna, uses a 
serum which differs from that of Aronson and Marmorek in that 
the streptococci in immunizing the horse were taken directly from 
man and without raising their virulence by passage through the 
lower animals. The animals were immunized by cocci from many 
instead of a single source. The dose of this serum varies from 100 
to 200 cc. In Eschericlr's report of 112 cases treated with this 
serum, he claims that in from four to twelve hours the tempera- 
ture dropped; the pulse and respiration slowed down; the stupor 
and delirium disappeared; the general condition improved and the 
eruption faded. The serum causes transient exanthemas in about 
75 per cent, of the cases. Since the use of the serum ulceration 
of the throat and suppuration of the glands have been less frequent. 
One striking feature of Eschericlr's report is the following: Of 27 
cases injected within the first forty-eight hours of the disease, none 
died; 2 of 27 injected on the third clay died, and 6 of 20 injected 
on the fifth day; a mortality ranging from nothing during the 
first and second day, through 7.4 per cent, the third ; 17.4 per cent, 
on the fourth to 30 per cent, on the fifth day, a result striking in 
similarity to that following the use of antitoxin.* Owing to 
difference in virulence of the various epidemics, and even of periods 
of the same epidemic, it is difficult to draw satisfactory conclusions 
as to the value of these methods of treatment. 

In my own service at the Cook County Hospital, comprising the 
period from February, 1895, to April, 1906, there were treated 
1672 cases with 125 deaths, or a mortality of 7.49 per cent., show- 
ing that the disease did not occur in a very virulent form during 
these years. A change in the epidemic was noted in December, 
1905; in the following four months there were 265 cases with a 
mortality of 13.6 per cent. 



*Zanghofer, v. Bokay and Quest report a similar experience follow- 
ing the use of the Moser, also a polyvalent serum. 



INFECTIOUS DISEASES 81 

Diet should, for the most part, be light, consisting chiefly of Diet 
milk. The large quantity of water contained in it is of great value 
in these cases, especially toward the end of the third week, if there 
be no nephritis or other contra-indications. Diet can be gradually 
increased in quantity and variety. In the fifteen years elapsing 
since Jaccoud employed milk as a diet, he has not had a case of 
nephritis after scarlet fever. My own experience has not been quite 
as favorable. 

The early treatment should be directed towards securing free Elimination 
elimination by way of the bowels and kidneys. This, when suc- 
cessfully accomplished, will in a large measure prevent the grave 
cardiac and renal disturbances. 

In many cases within a few hours from the first eruption, or 
even before its appearance, delirium or unconsciousness develops, 
accompanied by suppressed or scanty urine. The urine is loaded 
with albumin, some casts and occasionally blood. These fulminant Fulminant type 
cases should be treated by venesection and transfusion with normal 
salt solution. Water should be given from the onset in large quan- 
tities and diuretics employed. The best and safest is an infusion 
of birch leaves, 30 to 100, cc. given in two tablespoonfuls doses every 
hour. This causes neither heart depression nor nausea, and usual- 
ly results in a rapid increase in the kidney elimination. 

The fever should be combated by means of the cold bath or Baths 
sponging with cold water (antipyretics should never be employed). 
The reasons for the use of baths may be best stated in the words of 
von Jiirgensen; "The difference between the temperature of the 
body surface and the water that comes in contact with it are the 
determining factors. At the very moment that cold water comes 
in contact with the skin, deep respirations ensue, which not only 
cause a complete distention of the lungs, but must have a consid- 
erable influence upon the circulation. 

"The heart, which during the superficial breathing is working 
under difficulties, is now relieved of the burden to a considerable 
degree, and receives more and a better quality of blood. Owing 
to this, its vitality and functional power increase. If the tempera- 
ture of the body is increased, the number of the heart beats de- 
creases with the cooling caused by the radiation of heat to the 
water surrounding the body. The intervals between the single 
beats become longer, the diastolic storing away of the blood in the 
heart becomes greater, and the heart in this way becomes qualified 
for better work. At this point begins a more rapid and copious 
circulation throughout the entire system, and with it the possi- 
bility of throwing off the toxin." 

The cold baths should last but a few minutes and the water 
should be at a temperature of about 65° F. Where the cerebral 



82 



INFECTIOUS DISEASES 



Urotropin 



Nephritis 



The nose and 
throat 



Otitis 



symptoms are marked the ice pack can be applied to the head and 
cold douches can be given to the back of the neck, and at intervals 
along the spinal cord. If the skin is cold and the temperature 
high it denotes marked cardiac weakness and warm baths should 
be given. The contra-indications to the use of cold baths are car- 
diac weakness, organic disease of the heart, dyspnea due to steno- 
sis of the upper air passages, hemorrhages from the nose, mouth, 
or a hemorrhagic diathesis; also when joint inflammations are 
present. 

Widowitz reports 102 cases in which urotropin was employed 
without a single case of nephritis; others have used it, some with 
similar results and some claiming that it has no effect. The dose 
varies with the age of the patient and is given three or four days 
in the beginning of the attack, and for three days at the beginning 
of the third week. 

When nephritis develops the bowels should be kept free by the 
administration of repeated doses of magnesium sulphate, and the 
infusion of birch leaves given in large quantities, or the mixture 
of iron and ammonium acetate. The latter seems to do well in 
those cases where the nephritis is associated with anemia. When 
uremic symptoms develop very hot baths at a temperature of 110° 
F. should be employed. 

In cardiac weakness camphorated oil given hypodermically is 
probably the best stimulant. Infusion of digitalis with strychnin 
can also be employed. 

The early infection of the nose in the case of very young 
children should be treated by dropping a few drops of a solution 
of sodium bicarbonate, 1 to 200, into the nostrils ; older individuals 
employing it in the form of a douche. After each douche a little 
sterilized vaselin should be applied to the nostril. The severe 
angina if pseudo-membraneous is usually due to the presence of the 
Klebs-Loefner bacillus and 5,000 units of antitoxin should be ad- 
ministered at once. Painful angina is much relieved by allowing 
the patient to swallow small pieces of ice and applying the ice 
pack about the throat. Enlarged and suppurating cervical glands 
should be incised when there is fluctuation, or earlier when the 
tension becomes too great. The Crede ointment has proven use- 
less in the treatment of the enlarged glands. The ears should be 
examined frequently as an otitis media due to extension of the in- 
flammation from the throat through the Eustachian tube is a quite 
common complication. Should an otitis develop, paracentesis 
should be done at once and the ear irrigated every two hours with 
a hot boric acid solution until the discharge ceases. Mastoid in- 
fections are extremely rare when this method of treatment is fol- 
lowed. 



INFECTIOUS DISEASES 83 

MEASLES. 

(By Dr. W. L. Baum, Chicago.) 

The almost universal susceptibility to measles and the fact that Prevention 
sooner or later almost every individual will be attacked give rise to 
the interesting question whether it be better to guard the public 
against this infection or allow general exposure in the hope that for 
a generation at least the disease will disappear? No one who has 
witnessed the ravages of a virulent epidemic with high mortality 
and severe complications, and their far-reaching influence upon the 
future of the patients, can for a moment question the advisability 
of protecting the public as much as possible, both by compulsory 
isolation of the individual attacked and such regulations as tend 
to limit the spread of the disease. Unfortunately the period of 
incubation, especially during the catarrhal stage, is capable of 
spreading the contagion. During prevalence of measles in a certain 
district public school teachers should be instructed to send home all 
children suffering from conjunctivitis or coryza, with instructions 
that they be examined by a physician. The finding of Koplik 
spots and the subsequent isolation of the patient may limit the 
spread of the disease. Disinfection of rooms and clothing, as 
employed in diphtheria and scarlet fever epidemics, will protect 
the community. 

The patient with an attack of measles should be placed in a The sick room 
well aired room kept at a temperature of 65° F. The air of the 
room should be kept moist because of the universal involvement of 
the mucous membranes. Dry air increases irritability of the bron- 
chial tubes and predisposes to the most dreaded of all measles com- 
plications — broncho-pneumonia. The room should be partially 
darkened to protect the eyes ; once a day the light should be freely 
admitted to make a careful examination of the conjunctiva and 
cornea. As a rule the eyes need no further care, but where there 
is much irritation an ointment of the yellow oxide of mercury, 1- 
100, can be applied to the lids. 

The nose should be treated by dropping a small quantity of a The " ose and 
solution of sodium bicarbonate, 1-200, into each nostril and the sub- 
sequent application of vaseline or oxide of zinc ointment. The 
throat and mouth should be washed out with a mild antiseptic so- 
lution — boric acid solution, 1-100, or potassium permanganate, 1- 
500. Laryngeal spasm should be controlled by the administration 
of a small quantity of Dover's powder suitable to the age of the 
patient. In severe cases warm baths are indicated. When the 
stenosis is due to swelling of the mucous membrane or to the forma- 
tion of a plug of mucus in the trachea and larynx, an emetic should 
be given at once; apomorphin given subcutaneously acts most 



84 



INFECTIOUS DISEASES 



Fever 



Broncho-pneu- 
monia 



Diarrhea 



Diet 



promptly. If these do not give relief, intubation or tracheotomy 
should be employed. 

For the fever antipyretic drugs should not be employed. Baths 
at a temperature of 85° F., or sponging, will reduce temperature. 
If there be much nervous irritability small doses of potassium bro- 
mide can be given in conjunction with aconite. 

Measles patients who develop broncho-pneumonia, that most 
dreaded of all complications, should be at once isolated from other 
cases of the disease. A cold pack may be applied, but with small 
children care should be taken that they do not become chilled. This 
tendency can be overcome by application of heat and friction to 
the extremities. The heart may be stimulated by the hypodermic 
use of camphorated oil. 

Where diarrhea is a feature of the eruptive stage treatment 
therefor is as a rule not necessary. Should it persist, small, fre- 
quently repeated doses of bismuth subgallate, with enemas of nor- 
mal salt solution every four hours, will usually relieve the condition. 

Extension of inflammation from the throat may lead to a sup- 
purative otitis media. This if not relieved, leads to infection of 
the mastoid, necessitating operative interference. 

Weiss claims that by placing pledgets moistened with weak sil- 
ver solution in the nostrils and carrying them backward by pres- 
sure, he has reduced the percentage of otitis in measles from 27 to 
7 per cent. Should suppurative otitis develop, the drum should 
be incised and irrigations of hot boric acid, 1-100, or protargol, 
1-300, every three hours should be employed and kept up until the 
discharge disappears. 

During the eruptive period the diet should consist of milk, 
eggs, and foods easily assimilated; later this may be increased 
to the full, regular diet during the period of convalescence. 

The patient with uncomplicated measles should be isolated for 
at least twenty-eight days ; cases with persistent discharge from the 
nose or ears, for a longer time. 



Classification 
of preventive 
means 



SMALLPOX. 

(By Dr. Heman Spalding, Chicago.) 

The treatment of variola should begin with a consideration of 
the proper application of known preventive measures. Measures 
commonly employed and known to be efficacious in preventing 
smallpox are: 

1. Notification of cases and suspected cases of smallpox to 
Boards of Health or Health Officers. 

2. Quarantine and isolation. 



INFECTIOUS DISEASES 85 

3. Disinfection of infected persons and premises. 

4. Vaccination. 

NOTIFICATION. 

That prompt preventive measures may be taken by the right- ? e ^ £ tS r^° 
fully constituted health authorities or health officers in states, 
cities and towns, there should be state laws and city ordinances 
enacted, requiring, under penalty, a prompt report to the health 
officer of all infectious diseases. Cities have health ordinances 
and health officers to whom reports can be made. Some towns and 
villages are not thus provided, and when they are not, reports 
should be made to the county health officer or the state board of 
health. Physicians should promptly report any suspected case of 
variola. Owing to the lack of opportunity to see variola, the ablest 
of practitioners are liable to find it difficult to make an early diag- Early diagnosis 
nosis of this disease. Any eruptive disease not certainly understood 
should be promptly reported to the health officer as suspicious, 
throwing the responsibility of making a diagnosis upon that officer, 
who is, or should be, especially qualified for this work. It is the 
health officers duty to see that the physician who reports a suspect- 
ed case of smallpox suffers no loss of confidence from the patient 
or his friends. The protection of the physician's interests is easily 
accomplished if the health officer is tactful and ethical, as he al- 
ways should be. 

QUARANTINE AND ISOLATION. 

If the victim of smallpox is to be treated at his home, as is Guards 
the practice in small towns and the country, a strict quarantine of 
the house must be maintained. As no quarantine is effective if not 
complete, guards for the house must be stationed day and night, 
and no one except the attending physician or health officer allowed 
to enter or leave the infected house. 

The doctor should have a robe or a long rubber coat hanging Personal care 
outside the house to put on while vsiting the patient, to be again of physician 
removed upon coming out. He should then wash face, hands and 
hair in a 1 to 500 bichloride of mercury solution and sponge 
off his clothes and soles of his shoes with the same solution. While 
in the house visiting the patient, the doctor should avoid, when 
possible, touching anything except the floor with the soles of his 
shoes. If there is no contact with anything infected, there is lit- 
tle liability of carrying infection to others. 

To quarantine smallpox in the house is expensive and less ef- Home disin- 
ficient in checking the spread of the disease than is the practice of Action 
taking all patients to an isolation hospital. In the latter practice 



86 



INFECTIOUS DISEASES 



Care of persons 
exposed 



the patient is at once taken to the hospital in a carriage or ambu- 
lance. Those suffering with the mild form of the disease, and even 
some of the severer cases, when found on the first day of the erup- 
tion, prefer to go in a carriage. At this period of the disease they 
usually are able to sit up and walk. All persons exposed to the 
case are vaccinated and the persons and premises disinfected with 
formaline and a free use of bichloride of mercury solution, 1 part to 
500 of water. If the victim of the disease has remained home 
through the pustular stage of the disease, it is safer to burn the 
mattress and all bed covers used which cannot be immersed in the 
bichloride solution and boiled. Nothing should be taken from the 
infected house, even to be burned, that has not first been wet with 
the bichloride solution. 

After the patient is placed in the hospital and the inmates of 
the infected house and the premises are disinfected, and if all the 
inmates have submitted to vaccination and will obey orders, no 
quarantine is necessary. All those exposed are required to be at 
home where they can be seen at least every other day for eighteen 
days. In no other respect need their movements be restricted. 
They are advised to stay away from public gatherings and to re- 
main at home as much as possible, to escape criticism from neigh- 
bors. 

The moment any of the exposed shows symptoms of the dis- 
ease, he is placed in a room and the other inmates required to stay 
in the house. When the eruption appears, which occurs on the eve- 
ning of the third or morning of the fourth day of the disease, the 
diagnosis is complete, and the patient now in turn is taken to the 
isolation hospital and the house is again disinfected, but now there 
are no unvaecinated persons who are exposed. The house is free 
from smallpox and no further watching is needed. 



Method of 
infection 



dis- 



Preparation of 
rooms and con- 
tents 



DISINFECTION. 

In addition to burning mattress and bed covers not easily dis- 
infected by the soaking in a disinfecting solution and boiling, and 
the free use of the disinfecting solution, a formaldehyde disinfec- 
tion should be made as follows : 

The house to be disinfected is sealed and prepared as usual for 
sulphur disinfection by pasting strips of paper over cracks of doors 
and windows. All its surfaces are exposed as much as possible; 
closet doors are opened and their contents, together with the con- 
tents of drawers, are removed, scattered about and the drawers 
left open ; mattresses are set on end ; pillows, bedding, clothing, etc., 
are suspended from lines stretched across the rooms, or spread out 
on chairs or other objects so as to expose all sides; books are 
opened and the leaves spread — in short, the rooms and their con- 



INFECTIOUS DISEASES 87 

tents are so disposed as to secure free access of the gas to all parts 
as fully as possible. 

For every 1,000 cubic feet of space in the house, suspend by one Formalin 
edge an ordinary bed sheet (2x2% yards) from a line stretched 
across the middle of the rooms. Properly sprinkled, this will car- 
ry without dripping eight ounces of formalin — the 40 per cent, 
solution of formaldehyde gas — which is sufficient to disinfect 1,000 
cubic feet of space. As many sheets as necessary are used, hung 
at equal distances apart. The ordinary rather coarse cotton sheet 
should be used in order to secure rapid evaporation. The house 
should remain sealed not less than eight hours. 

When an isolation hospital is to be built, or hastily provided 
as is usually the case, see to it that the structure is good enough 
to be occupied by the best citizens. It should be a place to 
which the mayor and members of the council would be willing to 
take members of their families if any should be stricken with small- 
pox. 

A proper method of handling smallpox is fairly revealed in the 
writer's written instructions to medical inspectors with whom he 
has been associated in suppressing smallpox in Chicago, which reads 
as follows: 

"Medical Inspectors must keep in close touch with the Depart- Duties of med- 
ment of Health, so they may be reached without delay when wanted. lca ins P ec ors 

"When notified of a suspected case of smallpox^ the inspector 
must go to the case forthwith. An hour's delay may result in many 
needless exposures. 

"The following suggestions as to conduct in the presence of 
smallpox should be observed so far as the circumstances of the 
case will permit with safety. The inspector must supply any de- 
ficiency in these instructions which the case may demand for the 
safety of the public. 

"On entering the house where there is a suspected case of con- 
tagious or infectious disease, do not remove your hat or overcoat; 
keep the overcoat buttoned. 

"Do not shake hands with any one in the house. Do not sit- 
down or touch anything in the house, and especially avoid touching 
the patient or bed clothing. To expose the patient for examination, 
call upon the patient or some one present to remove the clothing 
for you. When leaving the house, have some one open the door, 
so as to avoid touching any infected door knob. 

"Except to vaccinate the inmates of the house, it is not neces- 
sary to touch anything about the premises, except the floor with 
the soles of your shoes. If these precautions are observed there is 
no danger of carrying the disease to others. 

"When it is determined the case is one of smallpox, fill out the 



88 INFECTIOUS DISEASES 

history blank provided for the purpose, telephone the information 
to the department, and promptly mail the filled blank to the Chief 
Medical Inspector. Telephone instructions as to the disposal of 
the case, whether an ambulance or a carriage is needed, the amount 
of disinfecting to be done and the number of vaccinators needed. 

"In filling out the blank, secure a list of all who have in any 
way been exposed to the contagion since the first day of the sick- 
ness, learn if letters or laundry have been sent out of the house, 
and where and to whom sent. Give the vaccinal status of those ex- 
posed as far as you can. 

"It is the duty of the inspector to vaccinate, or see that some 
other medical inspector vaccinates, all who are known to be ex- 
posed to the infection; do not leave or allow this duty to be done 
by the family physician. It is the duty also of the inspector to 
secure the consent of the patient or family for the removal of the 
patient to the isolation hospital. Do not leave this duty to the am- 
bulance driver. 

"Until the ambulance comes the case must be made safe. If it 
is necessary to police the house to secure safety, do so. After secur- 
ing the prompt vaccination of all exposed, it is the inspector's duty 
to see the exposed every other day for fifteen or twenty days. Ee- 
peat the vaccination every day for three days without waiting to 
see the result of the first trial. 

"If there is doubt about the diagnosis, vaccinate the inmates 
of the house, make the case safe to others and see the patient later. 

"A medical inspector must be courteous and should be tactful 
in all his relations to cases of smallpox, the same as a doctor should 
be in his private practice. He should be a complete master of the 
situation, able to dispose of complications and duties as they arise, 
in a proper manner. It should not be burdensome to do so, for the 
reward is always present, the consciousness that it is life-saving 
work. Use discretion and secure compliance with the ordinance 
without force. This can almost always be done, but if necessary the 
police power can be used to enforce compliance with the law. 

"You should read and familiarize yourself with the City Or- 
diance relating to sanitary work." 

VACCINATION. 
Value of vac- All preventive measures against smallpox are insignificant by 

cination ^e g -^ e Q ^ vaccination. If vaccination and re-vaccination were 

properly performed and universally applied, the consideration of 
palliative and curative remedies would be superfluous. Vaccination, 
with re-vaccination until the susceptibility to vaccine is exhausted, 
is an absolute protection against an attack of smallpox. A person 
thus vaccinated cannot contract smallpox. 



INFECTIOUS DISEASES 89 

A successful vaccination is characterized by vesiculation, pus- 
tulation, mild and limited inflammatory area with febrile reaction. 
In about twenty days from the beginning of the vesicle the result- 
ing scab comes off. This leaves a scar which is typical, if there is Effects 
no extraneous infection to cause inflammation and sloughing. Such 
a vaccination can be secured by using potent lymph which has been 
freed from pathogenic germs by mixture with glycerine. This vac- 
cination is protective against smallpox for about ten years. Some- 
times this single vaccination is protective for a lifetime, but oc- 
casionally a person is again susceptible to a mild attack of small- 
pox in a little less than ten years from date of vaccination. 

Every child should be vaccinated before the age of six months, Age and peri- 
and again in from seven to ten years. The operation should be ciifation 1 ^ 30 " 
repeated at periods of seven to ten years during life to make sure 
the protective influence has not been partially exhausted. If it 
fails to take it gives no inconvenience and does no harm. If it 
takes, it proves that the former vaccination is not now, at the time 
of the retrial, wholly protective. All persons not having had small- 
pox are susceptible to vacinia at least once. Eepeat the operation 
a dozen times if necessary to secure a successful result. The state- 
ment that this or that one is insusceptible to vaccinia — and conse- 
quently smallpox — is responsible for many deaths from smallpox. 
The writer saw a cashier of a bank die of hemorrhagic smallpox 
a few years ago, who had been vaccinated five times — all failures. 
His physician told him he was insusceptible to vaccinia and need 
not fear smallpox — a bit of false professional advice which cost a 
useful man his life at the age of 33 years. Inert lymph or faulty 
technique are responsible for most failures to secure typical result. 

To perform the operation, sterilize the skin, preferably of the 

left arm — the right if the subject is left-handed. If the subject 

is a girl, a place high up on the arm near the shoulder; in men 

and boys at the insertion of the deltoid. Use glycerinated lymph 

and blow the lymph — not with the breath, but with the rubber 

bulb furnished for the purpose — on the disinfected skin before 

scarifying. Take the arm in the hand, and by pressure make the 

skin on the upper aspect a little tense. Then with the point of a 

dull, sterilized needle, go right through the drop of lymph, and with 

slight pressure, irritate and abrade the skin, covered by the drop, 

until it is red. Lay bare the cutis vera ? but do not bring blood. You 

cannot always avoid bringing a little blood, but if a dull needle is 

used with slight pressure blood will seldom flow. Scarify a space 

exactly one-eighth of an inch in diameter, this size : f| 

Make but one mark. Vaccinia is a systemic disease, and a sin- Technique of 
i . t , . . , _ . on • ■ -i • • vaccination 

gle inoculation should be as efficacious in producing vaccinia as a 

greater number, unless there is an interval of time between the 



stage 



90 INFECTIOUS DISEASES 

vaccinations. The observations that have been made upon sub- 
jects with one, two, three or more scars, have led many to believe 
that two or more scars are more protective from smallpox than 
one scar. This I believe applies only where a period of time elapses 
between the production of a first, second and third scar. A dull 
needle is the best instrument to use for vaccinating; it is cheap, 
easily sterilized in a gas jet or flame of a lighted match, and does 
not terrorize children. 

For convenience and clearness of understanding the curative 
and palliative treatment of smallpox, it is best to consider the 
treatment as applied to the disease in its various stages — the in- 
cubative stage, the invasion stage, the eruptive stage and the stage 
of desiccation. 

THE INCUBATIVE STAGE. 
Treatment of During this stage nothing is known to be of any benefit in stay- 

i!UoJ nC tlve ing the disease after the reception of the infection into the blood, 
except vaccination, and that is of use only when applied during 
the first three days after receiving the infective agent. Vaccination 
will always prevent the disease if applied the first two days after 
exposure to the same, and will, in the great majority of cases, pre- 
vent the disease when made use of on the third day after exposure 
to the smallpox infection. On the fourth and fifth days, perhaps 
the sixth, if tried, vaccination will modify the disease, but after 
this time it has no modifying effect. 

A person exposed to smallpox should be vaccinated without 
delay. Eepeat the operation the next day, and continue to vac- 
cinate daily until you are sure one of the vaccinations is beginning 
to "take," then stop. By this method it is almost a certainty that 
you will secure a successful vaccination in the first three days' 
period, which insures the safety of the individual. When this 
practice is followed three or four vesicles may and often do result, 
but it saves life. If one vaccinates the first day of exposure, and 
waits to see if it "takes" before making another attempt, it results 
in the case of failure in losing all chance of preventing the disease. 
In other words, we have three days or chances to prevent the dis- 
ease, and use but one. It is safer to make good use of the three 
chances. 

If vaccination is not resorted to early enough to prevent the 
disease, the victim must meet one of the most formidable and dead- 
ly foes known to the human race. Anything that can be done to 
increase the power of resistance to disease should be done at this 
stage. 

Dr. I. D. Eawlings, of the Chicago Isolation Hospital, has 
practised and advocates the placing of a person known to be ex- 



INFECTIOUS DISEASES 91 

posed to smallpox in training for the fight with the approaching 

disease. He forbids alcohol in any form — the popular prophylactic Sustaining ef- 

with the laity — and places the subjects upon a good nourishing 

diet; keeps them in the open air as much as possible, and gives 

them regular and helpful exercise. He promotes excretion by 

baths and such laxatives as may be needed. He aims to promote 

bodily vigor, and thus increase the resisting power against disease. 

The subject should be kept cheerful and hopeful by encouraging 

and reassuring advice. This is rational treatment. It fortifies 

the body against the exhausting influence of this truly frightful 

disease. Nothing further can be done during this incubative stage. 

THE STAGE OF INVASION. 

This stage — which usually lasts three days — exceptionally only Treatment of 
two days, and occasionally prolonged to four days— is the initial * he s . ta S e of 
febrile stage. All we can do in this period is to palliate distressing 
symptoms and promote comfort. For excessive fever, cool sponge 
baths, and ice to the head if the headache is severe. Some of the 
coal-tar preparations, as acetanilid, may relieve backache and head- 
ache. To aid excretion and help to reduce fever, liquor ammonia?, 
acetatis, two teaspoonfuls every two hours, is of some service. To 
relieve pain, codeine may be used. Convulsions in children in the 
beginning are best treated by hot baths, and, if persistent, chloral, 
well diluted with water to avoid irritating the stomach. The early 
pain in muscles and back is relieved by two or three capsules of 
acetanilid, grains iii; monobromate of camphor, grains ii, and ci- 
trate of caffein, grains i. Codeine may be added to this capsule if 
the pain is excessive. 

At this stage the nourishment should be cold milk, ice cream 
and water. 

As the stage of eruption approaches all the painful symptoms 
become intensified. Fever high, frequently 106° F., severe back- 
ache, intense headache, nausea, anorexia and sometimes delirium. 
To relieve these distressing symptoms, morphine given hypodermic- 
ally is the most effective, one-eighth of a grain, and repeat the dose 
in an hour or two if needed. The ice cap and morphine often re- 
lieve delirium. Bromides and chloral given for delirium are irri- 
tating to the sensitive stomachy while morphine is better borne. 
Cold sponge baths should be continued when the temperature is 
high, and if the patient is able to stand the exertion, and he usually 
is, he can be placed in a tub for a cold bath. 

On the evening of the third or morning of the fourth day the 
eruption on the skin appears, and all these distressing symptoms, 
as a rule, cease. The headache and backache are gone and fever 
usually disappears. In severe cases the temperature may remain 



92 



INFECTIOUS DISEASES 



up for twenty-four or thirty-six hours before dropping to the nor- 
mal. Exceptionally, the temperature may be continuous through- 
out the course of the disease. 



Treatment of 
the eruptive 
stage 



Mouth and 
throat 



Conjunctiva 



THE ERUPTIVE STAGE. 

As the eruption appears little treatment will be needed for a 
few days. The patient feels well, and the majority at this time will 
get up and walk or sit up. This is the period in the disease when 
the patient will walk out and visit the doctor's office, or take a trip 
on the railroad to visit friends. He should be kept in bed and 
given nourishing food during the several days of comparative com- 
fort he will now experience. At this time the appetite is quite 
good, and the patient can take with benefit to himself a pretty gen- 
erous diet. Semi-solids can be given freely, such as oatmeal and 
cream, milk-toast, custard, soft boiled eggs, rice and baked apples. 
The mild cases never having fever after the invasion stage, can eat 
steak, chicken, fish, oysters and vegetables. 

About the second day of the eruption the papules appear vesicu- 
lar and continue to grow larger and fill with serum until about the 
fifth day, when the contents turn white or milky in color. This 
is the end of the vesicular and the beginning of the pustular period. 
There is almost always absence of fever up to the beginning of the 
pustular period, and during the papular and vesicular periods the 
treatment, aside from feeding, is local — principally directed to the 
throat and mouth. The vesicles in the mouth and throaty covered 
with the thin mucous membrane, rupture early and leave super- 
ficial, sensitive and painful ulcers. If these lesions are treated 
promptly they will heal in advance of the skin eruptions. This is 
important, because the patient then can and will take nourishment 
much better in the later and more severe stage of the disease. Any 
good antiseptic mouth wash or gargle can be used. DobelPs solu- 
tion makes a good one. To this a little cocaine can be added if the 
mouth and throat are very sensitive and sore. This gargle can be 
used frequently. An atomizer can be used to throw the solution 
deep into the pharynx. 

Conjunctivitis, which is frequently noted, is due to the presence 
of one or more vesicles on the inner surface of the eyelids. It is 
best not to open these vesicles, as the rough edges of the incision ir- 
ritate the conjunctiva more than does the unbroken vesicle. Use in 
the eye freely a saturated solution of boric acid and firmly apply a 
compress and bandage to prevent use and movement of the eye. 
Movements of the eye increase the irritation, but the compress must 
be removed hourly, and the boric acid solution instilled into the eye. 
The vesicle may form upon the cornea, in such case there is danger 
of perforation and destruction of sight from deep ulceration. By 



INFECTIOUS DISEASES 93 

carrying out the above treatment for conjunctivitis much can be 
done to lessen the dangers from ulceration of the cornea. 

In this early stage all attempts to avert the approaching pustu- Cannot abort 
lar stage have been futile. In our experience none of the numerous 
remedies recommended for internal administration, with a view to 
aborting the lesions, have in the slightest degree modified the course 
of the vesicle or pustule. Puncturing the vesicle and cauterizing 
with a view to lessen the pitting, is a doubtful procedure. Inject- 
ing the vesicle with 1 to 200 bichloride of mercury solution, which 
has been advocated, proves to be useless. All kinds of applications 
to the skin have been useless in our hands in lessening destruction 
of tissue. We wrapped a hand and arm with a thick covering of 
Fuller's earth, glycerine and oxychlorine, and kept it covered with- 
out disturbance from the beginning of the papular to the middle of 
the pustular period. No local treatment was given the other hand 
and arm. When the dressing was removed it was found the lesions 
had gone on in their development the same in the arm treated as in 
the one receiving no treatment. Here also there was a complete 
exclusion of actinic rays of light, which has been lauded as capable 
of preventing the development of pustules. Of the red light treat- 
ment we will speak farther on. 

From the fifth day of the eruption on to the eleventh or twelfth 
day is the suppurative or pustular period of the eruptive stage. Critical period 
This is the period in which the majority of deaths occur. It is 
the time when the physician and nurse are most needed. Much can 
now be done for the comfort and safety of the patient. Unremitting 
care and watchfulness on the part of the doctor and nurse will pilot 
to recovery through this distressing period many cases which appear 
hopeless. 

At the beginning of this period, in severe cases, the fever re- 
turns. This is probably a septic fever. There is an inflammatory 
area about the pustule and much swelling. Burning and itching 
comes to torment the sufferer. The condition is similar to that of 
a man affected with thousands of small boils, upon a large number 
of which he must lay his whole weight. The torture is extreme. 
In the confluent form the condition is somewhat similar to an ex- 
tensive burn of the second degree. 

The indications for treatment during the pustular period of 
smallpox are : 

1st. To allay pain and prevent shock and exhaustion. 

2d. To support the patient. 

3d. To hasten desiccation. 

4th. To combat toxemia. 

5th. To treat complications. 



94 INFECTIOUS DISEASES 

Owing to the inflammatory condition about the pustules, the 
pain and distress of body at this period is very great. Fever, sleep- 
lessness and often delirium fast exhaust the patient's strength. At 
this time bromide and chloral have been given to relieve pain and 
induce sleep. These drugs are not well borne, nor are they efficient 
for the purpose of relief of the condition present. 

The painful period of acute inflammatory condition of the skin 
lasts usually from the evening of the sixth day to the morning of 
the ninth, in severe cases a day or two longer. During this time 
nothing gives so much relief from pain, itching, burning, sleepless- 
ness and delirium as morphia, one-fourth grain, repeated if need be 
every four hours. If a larger dose is necessary to secure results, 
give it. It is well borne and affords sleep and comfort. If there 
is any pre-existing nephritis, morphia should be used cautiously, 
if at all. 

Nourishment must be admitted, though there may be anorexia. 
A liberal quantity of milk, warm or cold as suits the patient, and 
ice cream are allowable. If the patient does not retain these, try 
milk with lime water, milk-punch, egg-nog and kumyss. If all food 
is rejected feeding by the rectum should be resorted to. In sup- 
port of patient tonics and stimulants must be used, as indicated 
by the condition of the pulse and temperature. Strychnia should 
be given as early as the time when the pulse shows weakness. Be- 
gin with the one-fortieth of a grain every four hours, and increase 
to one thirtieth grain, given with the same frequency. Brandy 
should be given for five or six days during the suppurative period, 
and longer if the patient is absorbing pus from the surface. Alcohol 
is undoubtedly valuable in the treatment of septic cases and those 
who were addicted to drink before the attack. Tincture of the 
chloride of iron and quinia are useful also in combating toxemia. 
Antistreptococcus serum was abandoned by us as useless after a 
fair trial. 
Serum The cases of true hemorrhagic smallpox are practically hopeless. 

They all die in six, ,or at longest seven, days. I have seen but one 
live to the seventh day. The same supporting treatment given 
above applies to these cases. Ergot, adrenalin and antistreptococcus 
fail to aid, though they have their advocates. 

Local applications during the pustular period, that have been 
so extensively used, I do not approve of. To allay itching during 
the vesicular and pustular periods, water with menthol can be used, 
and sponging for cleanliness and reducing fever, but this readily 
dries and does not retard desiccation. The smallpox lesion in its life 
history is like that resulting from vaccination. The natural history 
of the lesion is to fill with serum, turn pustular, dry up and scale 
off. Nothing should be done to retard this process. The applica- 



INFECTIOUS DISEASES 95 

tion of continuous baths, poultices, plasters, oils or salves of any- 
kind hinders desiccation. We do not use these applications on a 
vaccination before desiccation, and why should we try them in the 
treatment of smallpox ? 

The mild cases are best treated by arranging so that their bodies 
are exposed to the sunlight and air. This hastens the drying-up 
process and shortens the period of pustulation. This treatment I 
would not advise for confluent cases with secondary fever in warm 
weather, as the heat of the sun adds to the discomfort, but in the 
discrete cases it is not uncomfortable and I believe it shortens the 
course of the skin lesions. Even the patients in the wards notice 
and remark about those near the windows recovering more speedily 
than those farther from the windows and sun's rays. 

From January 1, 1899, to January 1, 1903, there were treated 
in the Chicago Isolation Hospital 690 cases of smallpox, mostly of 
the mild type. They were placed in the sunlight as much as pos- 
sible. The death rate was but 1.6 per cent. — a better showing than 
that recorded under the so-called Finsen ray or red light treatment, 
— the exclusion of the actinic rays of light by means of ruby red 
window glass. 

From January 1, 1903, to January 1, 1906, 1289 cases were 
treated in the same hospital with a death rate of 10.5 per cent. The 
disease had changed to the severe type. This is a low death rate, 
considering the severe type of the disease. These patients, with the 
exception of about seventy in the red light ward, were given plenty 
of light and air in wards with large windows on both sides and one 
end. About seventy of these patients were put in a ward from 
which the actinic rays were rigidly excluded. This red light treat- 
ment not only proved worthless, but was harmful. The red light 
gives patients in delirium the impression often that the house is on 
fire. Finsen claimed that this treatment, if begun the first day of 
the eruption, would prevent the formation of pus. In no instance 
in our experience (and we gave it thorough trial) did the treatment 
in any degree modify the course of the disease. The red light 
treatment for smallpox cannot be recommended. 

As the pustular period advances, the lesions rupture from the 
weight of the body, and the bed sheets stick to the raw surface of 
the lesions. The sheets should be dusted with a powder composed 
of boric acid and subgallate of bismuth. Sheets must be changed 
several times daily when the pustules begin to break down. Warn 
patients against scratching the face. Adults can be influenced not 
to scratch the lesions, but children cannot resist the itching, and 
should have their hands enveloped in cotton covered by sterile gauze. 
This will prevent scratching. If the itching cannot be resisted, it 
is better to delay desiccation by applying carbolized vaseline 3 per 



96 



INFECTIOUS DISEASES 



cent., to which is added 2 per cent, menthol. Or oxide of zinc oint- 
ment, to which is added one drachm of campho-phenique to the 
ounce, and 2 per cent, of menthol. If the pustules run together and 
become large blebs filled with pus, resembling the blisters from 
burns, the contents may be let out by incision and the dusting pow- 
der freely applied. This condition is often seen on the hands and 
wrists. 



Treatment of 
stage of desic- 
cation 



THE STAGE OF DESICCATION. 

When the pustules are dried, forming scales, the patient is ready 
for antiseptic baths, which loosen the scabs and disinfect the sur- 
face of the body. The baths found most efficacious are bichloride 
of mercury 1 part to 1000 of water; and equally as good perman- 
ganate of potash enough to color the water a light pink. Then the 
protecting salves can be freely applied. As all pustules are dried 
now, salves will soften and hasten desiccation. Nourishment should 
now be given freely. Semi-solid diet, and in a few days solid food, 
can be taken with advantage. The appetite is usually good, and a 
substantial diet can be given, including meats. If there is anything 
the patient needs now it is food, and he should have three meals 
daily and a lunch between meals. This is the stage when abscesses, 
boils, local surface infections, impetigo, erysipelas and gangrene are 
found, though gangrene of the scrotum has occurred in the pustular 
period. All complications of this kind should be treated the same 
as when encountered unaccompanied with smallpox. Pneumonia, 
bronchitis^ pleuris}^, laryngitis and nephritis may occur. The diet 
must be restricted in case of nephritis. 

In mild cases no "pitting" remains after recovery. In the 
severe cases there is no treatment which we have tried that will 
prevent pitting. Smallpox, like other morbid processes, is a disease 
of degree. Some will have small pustules with a comparatively 
mild inflammatory manifestation. Some cases will even abort in 
the papular or vesicular period and escape the inflammation of the 
pustular period. If the pustules are large and well filled with pus, 
and if the epidermis is thick and tenacious, the pus will be held 
down under the pressure until the inflammation extends through 
the cutis vera. Destruction of skin, with "pitting" is the result. 

To summarize : Smallpox is absolutely preventable by vac- 
cination. 

There is no known medicine which in any way modifies the 
disease once it is well started. 

The treatment consists in intelligent nursing and the use of 
such palliative and supporting remedies as are known to give and 
conserve strength. 



INFECTIOUS DISEASES 97 

YELLOW FEVER. 

(By Dr. Albert J. Mayer* and Dr. Urban Maes, New Orleans, La.) 

In yellow fever we are today, as with many other diseases, with- 
out a specific. The treatment is entirely symptomatic. In the 
antitoxin of Sanarelli, discovered in 1895, and published in 1897, it 
was hoped that a specific had been found, but experience showed its 
inefficiency. 

In order to intelligently treat yellow fever symptomatically it 
is necessary to touch briefly the various phases of the pathology of 
the disease as they arise. Primarily, we must remember that yellow 
fever is an acute, infectious, febrile disease caused by an, as yet, 
unknown organism. Th toxins of this organism, circulating in the 
blood, have certain deleterious effects on the human economy, 
briefly, as follows : 

1. They act as a medullary poison, exerting an early influence 
on the vomiting centers. (This symptom is partially due to the 
capillary stasis in the stomach with mucous and sub-mucous 
hemorrhages.) 

2. They produce vaso-motor paresis, hemolysis and disintegra- 
tion of the capillary walls by fatty degeneration, which is part of 
the general steatosis. 

3. They cause pathological changes (fatty degeneration) in 
the liver and kidneys, characterized by jaundice and usually by an 
acute desquamative nephritis. 

At the first appearance of the symptoms of the disease the Hygiene 
patient must be put to bed. Kest, both mental and physical, is an 
absolute requirement. The patient must not be allowed to raise his 
head off the pillow. Defecation and urination must be performed 
in the recumbent posture and the supply of fluids should be admin- 
istered by means of a tube or feeding cup. The best observers are 
unanimous in agreeing that these statements are to be taken in 
their most literal manner and the physician cannot afford to deviate 
from them in the slightest particular from the first moment of 
attack. 

After being put to bed the patient is clad in the lightest of gar- 
ments so arranged that in order to sponge him it will be unneces- 
sary to put him to the slightest exertion. A tepid cleansing bath is 
given and the patient is placed in the best lighted and ventilated 
room in the house. Measures of hydrotherapy which may later 
become necessary must be done with the utmost gentleness, in fact 
some observers go so far as to claim that yellow fever being a self- 
limited disease it is better to ignore the pyrexia on account of the 



: Deceased. 



98 INFECTIOUS DISEASES 

accompanying disturbance of bathing. They believe that the py- 
rexia is far less dangerous than the moving of the patient. We 
think, however, that a certain amount of personal cleanliness adds 
to the comfort of the patient and does much towards hastening 
convalescence. 

A mouth wash of some alkaline antiseptic solution as chlorate of 
postassium is of service in diminishing the tendency towards 
gingival hemorrage besides alleviating the bad taste. Enemata of 
soap suds and water should be given every day or every other day 
according to indications, but care must be taken not to irritate the 
rectum, as it may be our sole reliance for sustaining and treating 
the patient. 
The foot bath From time immemorial the initial measure of treatment which 

has stamped itself most emphatically upon the minds of the prac- 
titioners in the localities subject to the invasion of "Yellow Jack" 
has been the mustard foot-bath or the foot-bath a la Creole. 

A foot-tub is partially filled with warm water to which is added 
a pound of freshly ground mustard dissolved in cold water. This 
tub is placed in the bed ; the feet of the patient are then immersed. 
The patient and tub are covered with two or three woolen blankets. 
Every three or four minutes a pint of almost boiling water is added 
to the bath, the feet and legs of the patient being rubbed rather 
vigorously. The sudorific effect of the bath must be kept up for at 
least ten minutes and its effects aided by the giving of hot aromatic 
drinks, hot lemonades or teas. 

This has been in such universal use in New Orleans in the 
epidemics of '53, '65, '78, '97 and 1905, that a physician is rarely 
called to see a case where this step has not been taken by some mem- 
ber of the household, and supplemented by wrapping in blankets 
and the administration of some hot ; aromatic drink to serve as a 
diaphoretic and diuretic. There is no doubt that in its present form 
it is of decided value in relieving the head symptoms and the con- 
gestive phenomena of the first stage of the febrile paroxysm. 
(Matas.) 

If the case is seen early an initial purge of calomel in small 
doses should be given and followed, if the stomach permits, by some 
saline cathartic. After the first stage of the disease is passed and 
the capillary stasis becomes marked, with nausea present, acting as 
an index of the congestion of the internal organs, it is not advisable 
to use this routine. The predisposition to gastric hemorrhage may 
be thereby augmented, consequently the laxative enema is 
preferable. 

The cephalalgia and rachialgia are best met by topical applica- 
tions, the ice-bag to the head and the mustard plaster or other 
counter-irritant to the loins. The coal-tar derivatives and other 



INFECTIOUS DISEASES 99 

sedatives, such as codeine and morphine, are only mentioned in this 
connection to be condemned. As has already been shown the toxins 
exert such a potent influence on the organs of elimination and cir- 
culation that it is unwise to tax them further. 

The remedies which have been lauded for the nausea are legion. 
The entire group of anti-emetics, including carbolic acid, cerium 
oxalate, cocaine, creosote and the much vaunted bichloride lem- 
onade of Sternberg have proven non-efficacious. The simplest treat- 
ment is the best. When cracked ice, carbonated drinks or iced dry 
champagne fail to relieve, it is the wisest plan to give the stomach 
absolute rest and supply fluids and other nutriment by rectal ad- 
ministration. 

That usually ominous sign "black vomit," or gastric hem- 
orrhage, is best met with perchloride of iron. (Guiteras.) This 
writer also claims that in hemorrhages from other mucous mem- 
branes (gingival, intestinal and uterine) this drug has given him 
the best results. His experience with adrenalin has not served to 
recommend its use. Ergot, digitalis and aconite have also been 
recommended but have not given good results. Counter-irritation 
over the stomach, ice-bags, mustard plasters, blistering with can- 
tharides or the actual cautery, and dry cups are of little value. 

Temperature is best controlled by hydrotherapy. The tub bath Pyrexia 
as used in typhoid is never employed in this malady, but sponging 
and packing are the measures most often resorted to. Enemata of 
cool water can also be used as a means of reducing the temperature 
and stimulating the patient. In addition they furnish the body 
with the fluid so necessary for the dilution and the elimination of 
the poisons of the disease. 

In Las Animas Hospital hydrotherapy was used to the complete 
exclusion of drugs, and striking results were obtained by Gorgas, at 
this hospital. He says: "Generally when the temperature remains 
above 103° for any length of time I have the patients sponged every 
two hours with cold water." 

Because of the capillary stasis occurring in this disease the 
sponging is best accompanied by mild friction. Ice bags to the 
head and back of the neck are beneficial, insomuch as they are use- 
ful in the general scheme of hydrotherapy and are grateful to the 
patient. 

Here we again mention the whole group of antipyretic drugs to 
state that while they may have a certain limited field of usefulness 
they are not to be recommended as a routine. The use of the 
cinchona group has long since been abandoned. 

The most grave condition with which we have to contend is Anuria 
complete suppression of urine. This should not be confounded 
with simple retention which can be relieved by catheterization. The 



100 INFECTIOUS DISEASES 

possible occurrence of urinary suppression must always be borne in 
mind. Albuminuria, which appears in most cases on the third day, 
should, for safety's sake, be regarded as a forerunner of this condi- 
tion. Daily examinations of the urine are absolutely necessary. A 
scanty flow with an increasing albuminuria and microscopic find- 
ings, indicative of the severity of the kidney lesion, calls for ener- 
getic measures on the part of the attending physician. Once such 
a state is established, therapeutics are of little avail; consequently 
we should endeavor to forestall this condition by appropriate 
measures. 

When the stomach will allow, large draughts of hot or cold 
water, flavored or not, as best suits the patient, are to be given. The 
alkaline waters, such as Vichy (Celestin), Apolinaris and White 
Eock are of great value. The necessity of giving a large amount of 
fluids having been demonstrated, the rectum must be resorted to 
where the nausea proves intractable. Hypodermoclysis and 
intra-venous infusion with normal saline solution have been used, 
but it was the experience of Matas and others in New Orleans in 
'97 that when suppression actually existed even this was useless. 
The saline enema as suggested by Murphy (proctoclysis) may be 
tried. 

The diuretic drugs, more particularly the citrate and acetate of 
potassium combined with the infusion of digitalis, still have a more 
or less deserved reputation in the hands of some practitioners. 
Their usefulness cannot be doubted in mild cases and when em- 
ployed early in the attack. Dry and wet cups are also used. 

There is no disease in which we can less afford to dispense 
with the aid of a competent nurse. The value of her services can 
only be measured in terms of human life. With the innumerable 
calls that are made upon a physician's time in yellow fever stricken 
communities the necessity of accurately recorded observations ? espe- 
cially of pulse, temperature and the organs of elimination in each 
case, are of the highest value. There is no doubt that the profes- 
sional nurse is no small factor in the reduction of the mortality of 
yellow fever. To quote from Osier, "Careful nursing and a symp- 
tomatic plan of treatment give the best results/' 
Stimulants After the initial fever of forty-two to seventy-two hours' dura- 

tion we have a secondary rise and it is in, or following, this stage 
that the patient is most often brought face to face with death. 
Stimulation with strychnia in doses of one-sixtieth to one-thirtieth 
grain hypodermically every three to four hours, supplemented by 
mild alcoholics, preferably in the form of iced champagne and 
Ducro's elixir, panopepton, and the digested beef essences, are indi- 
cated at the first signs of failing circulation. In this secondary 
fever, called the fever of auto-intoxication by Sanarelli, various 



INFECTIOUS DISEASES 101 

intestinal antiseptics, more particularly salol, were faithfully tried 
in Havana but, as shown by Gorgas and Guiteras at Las Animas 
in 1900, they are of doubtful value. 

We have already spoken of the gastric irritability and what its Diet 
persistence means. All physicians are agreed, and it may be laid 
down as a dogmatic fact, that during the first four days of the 
disease no nourishment should be given except water, which may be 
supplied to the point of toleration. By the fifth day the crisis has 
usually passed, and we may then begin with milk in small quanti- 
ties^ plain, or with the addition of lime water. The quantity of 
nourishment is gradually increased with the addition of broths and 
strained soups. This liquid regimen should be continued until the 
beginning of the second week, when the patient may be allowed to 
sit up and begin a gradually increasing diet. 

While the present prophylaxis of yellow fever has only been es- Prophylaxis 
tablished since 1900, Finlay of Havana, as far back as 1881, had 
already given up the fomites theory and had begun to suspect that 
some blood-sucking insect acted as the intermediary host of the 
yellow fever organism. 

The peculiarities of the aedes (stegomyia) calopus, Meig, its 
methods of feeding, its universal presence in the zones liable to 
epidemics and its hibernation coincident with the disappearance of 
the disease in the zones of accidental infection, led him to direct his 
investigations towards that particular mosquito. In 1898 he an- 
nounced the following conclusions, on which was based the work of 
later investigators and upon which rests our present system of 
scientific control : 

1. That the germ of yellow fever is only pathogenic to human 
beings when introduced by inoculation. 

2. That the regular process by which the inoculation of the 
germ is accomplished in Nature, is through the bites of the culex 
mosquito {aedes calopus), the insect having previously become con- 
taminated through the act of biting a yellow fever patient within 
the first five days of his attack. 

3. That although the bites of a recently contaminated mos- 
quito can produce at most only a very mild attack of yellow fever, 
or simply confer patent immunity without eliciting any obvious 
pathogenic manifestations, the bites of the same insect when its 
contamination dates back from several days or weeks, might pro- 
duce severe or fatal attacks. 

4. That the yellow fever mosquitoes after they have once be- 
come contaminated retain the power of inoculating the disease dur- 
ing the rest of their lives. 

Carter's work* was to the effect: 



*New Orleans Medical and Surgical Journal, 1900. 



102 INFECTIOUS DISEASES 

1. That yellow fever was a house disease. 

2. That a house infected with yellow fever was not infective 
until a certain period of time had elapsed. He fixed this period at 
from ten to twelve days. It remained for the United States Army 
Commission under Dr. Walter Keed, consisting of Keed, Lazear, 
Carroll and Agramonte, to show conclusively that the blame be- 
longed to the female aedes calopus, thus confirming Finlay. Later 
commissions, notably those of the Liverpool School of Tropical 
Medicine, the Hamburg School of Tropical Medicine, working par- 
ties of the United States Public Health and Marine Hospital Serv- 
ice, and independent investigators, especially Guiteras, working 
along these lines further fixed upon the aedes calopus as the sole 
agent capable of transmitting the disease. 

Prior to 1901 sanitarians devoted their efforts to stamping out 
the disease in accordance with the theory of fomites, but the labors 
of the above mentioned scientists, and the work of Gorgas in eradi- 
cating the disease from Havana, its perennial home, showed clearly 
that the prophylaxis of the yellow fever lay in the destruction of 
the aedes calopus, for in the words of Carroll, "No mosquitoes, no 
yellow fever." 
Prophylaxis Yellow fever, distinctly an acute, infectious disease, is trans- 

general mitted from individual to individual, as far as we know, by the 

agency of the female aedes calopus, and therefore it can be eradi- 
cated as an epidemic by the destruction of this mosquito, and the 
individual can be safeguarded by being protected from the bites of 
an infected insect. 

In instituting prophylactic measures against yellow fever, we 
must bear in mind the following facts : 

1. That the yellow fever patient is capable of infecting the 
aedes calopus during the first three days of the disease only. (The 
yellow fever cadaver is not infectious.) 

2. At least twelve days must elapse before the bite of an in- 
fected mosquito can transfer the active poison to a non-immune. 

3. The period of incubation is from forty-one hours to five 
days and seventeen hours. (United States Army Commission.) 

4. No direct transmission from patient to patient has ever 
been recorded except by experimental inoculation. 

5. The infectious life of the aedes calopus ranges from twelve 
days to fifty-seven days (Eeed), to one hundred and ten days 
(Guiteras). 

In safeguarding the non-immune, it is obvious from the fore- 
going facts that the mosquito must be prevented from attacking 
the patient during the first three days of the disease. This is best 
accomplished by placing the sick person in a carefully screened 
room, which has been freed from mosquitoes by fumigation, and 



INFECTIOUS DISEASES 103 

under a mosquito netting which has at least 18 meshes to the inch. 
Further, the entire house, except the sick room, must be fumigated 
within twelve days of the onset of the fever, in order to destroy any 
mosquitoes that may have become infected prior to the recognition 
of the disease. And finally, the entire house, including the sick- 
room, must be again fumigated after the recovery of the patient. 
When this procedure is carried out, the danger to susceptible per- 
sons in the house and neighborhood is practically nil. This was the 
method pursued successfully in Havana by Gorgas, and his suc- 
cessors, except where it was possible, under a military regime, to 
remove the patient in a screened conveyance to Las Animas Hos- 
pital. In some cases of this nature, all the mosquitoes in the 
infected house were immediately destroyed by fumigation with 
pyrethrum. The evolution of yellow fever prophylaxis as prac- 
ticed on a large scale was best depicted in controlling the spread of 
the disease after it had gained a firm footing in New Orleans in 
1905. The successful and remorseless war raged, not against the 
invisible and unknown foe of former years, but against the well- 
known striped or tiger mosquito, will live forever in the annals of 
preventive medicine and sanitary science, as the most brilliant 
achievement in the history of any nation. 

In all cases where possible the following routine was followed: 
A room adjoining that of the patient was carefully screened and 
sealed; it was then fumigated with sulphur (two pounds to the 
thousand cubic feet), and thoroughly aired. The patient was then 
transferred to this room and the remainder of the house fumigated 
in the same manner. In cases seen after the first three days of the 
disease the patient was transferred to another room if possible, and 
the room fumigated in order to kill the infected mosquitoes before 
they could get out to deposit their eggs after their essential meal of 
blood. This killing off of the infected mosquitoes in the room itself, 
and the neighboring buildings, is the sine qua non in combating a 
yellow fever epidemic. 

Unsuspected cases, and cases not easily recognized, as are not 
uncommon among children, sometimes furnish hidden foci which 
remain as a source of infection to the entire vicinity. In instances 
of this sort, wholesale mosquito destruction becomes imperative. 
The breeding places must be ruthlessly destroyed. 

Guiteras, the greatest living student of yellow fever, recognized Maritime pro- 
three areas of infection. 

1. The focal zone in which the disease is never absent. This 
formerly included Havana, Eio, Vera Cruz, and the ports of the 
Spanish-American main. Thanks to the labors of the sanitary 
workers we can eliminate two of these, Havana and Vera Cruz. 



104 



INFECTIOUS DISEASES 



2. The peri-focal zone or regions of periodic epidemics. This 
zone includes the ports of the tropical Atlantic in America and 
Africa. 

3. The zone of accidental infection between the parallels of 
35° South and 45° North. The peri-focal and the zones of acci- 
dental infection can be protected from the introduction of the 
disease by efficient quarantine regulations preventing the ingress of 
infected persons from infected ports, and establishing such a period 
of detention that the disease may have time to develop before sus- 
pected non-immunes are allowed to enter a non-infected port. 



HYDROPHOBIA. 



Prophylaxis 



Virus 



Pasteur treat- 
ment 



General prophylaxis against hydrophobia is now commonly 
enforced. The muzzling of dogs as a general police regulation, and 
instructions in regard to thorough cauterization and antiseptic 
treatment of the wounds are necessary prerequisites towards the 
prevention of hydrophobia. Very little reliance, however, should 
be placed upon the purely local surgical treatment of bites ; for the 
virus may be carried within a few minutes beyond the reach of the 
cautery, the surgeon's knife or antiseptic solutions. Cauterization, 
however^ should never be neglected, for the use of the actual cautery 
no doubt destroys a sufficient quantity of the virus to prolong the 
incubation period, for the smaller the quantity of virus introduced 
throughout the incubation period and the longer the incubation 
period, the more favorable the chances of success by the Pasteur 
method of treatment. 

The virus is carried to the central nervous system through the 
peripheral nerves. The living virus itself seems to promptly reach 
the central nervous system, differing in this way from infection by 
tetanus, where the specific bacteria remains localized in the wound. 
The first manifestations of hydrophobia are always discovered about 
the segment of the central nervous system corresponding to the site 
of the wound. 

The virus is, as first administered by Pasteur, weakened in its 
virulence by dessication. The material employed is the spinal cord 
of a rabbit inoculated beneath the dura mater with an emulsion of 
the medulla of another rabbit that has died of hydrophobia. The 
animal from which the cord is to be obtained is killed by bleeding, 
the cord cut into two parts and each section suspended in a jar con- 
taining a suitable hygroscopic material, usually solid potassium 
hydrate. The jar is now hermetically sealed and desiccation al- 
lowed to proceed for fourteen days. At the expiration of this period 
the infectiousness of the cord has been so reduced that it can be 



INFECTIOUS DISEASES 105 

used for the first injection. Beginning with a cord that has been 
desiccated for fourteen days, cords that have been desiccated for 
shorter periods are gradually injected until virulent virus itself can 
be given with impunity. The vaccine itself is manufactured by 
emulsifying 1 cc. of a cord in 5 cc. of a normal salt solution and 
injecting from 1 to 3 cc. of this emulsion into the anterior abdom- 
inal wall. This region is selected because there are few large nerves 
there which can be injured. 

In some cases it may be necessary to proceed more rapidly from 
fourteen-day virus to fresh virus. In children, who are more sus- 
ceptible to hydrophobia than adults, in injuries about the face and 
neck and in ulcerated wounds with large absorptive surfaces, a more 
intensive treatment should be employed. If proper cauterization 
is used at once, the period of incubation is more apt to be prolonged 
and a more gradual course of preventive inoculation may be 
instituted. 

Whereas all individuals bitten by rabid dogs do not develop Prophylaxis 
hydrophobia, still in view of the harmlessness of a properly insti- 
tuted Pasteur protective treatment, every patient exposed should 
have the benefit of this method. The mortality statistics have been 
greatly modified by the Pasteur treatment. Fully a month must 
elapse after the beginning of the treatment before one can be cer- 
tain that immunity has been established, in so far as at least four- 
teen days must elapse after the completion of the treatment before 
the development of the disease can be definitely excluded. With an 
improved technique and greater accessibility of Pasteur Institutes 
in different regions of the world, the mortality from this frightful 
disease has been immensely reduced. 



CHOLERA. 

The specific treatment of cholera is so far rather unsatisfactory. Prophylaxis 
A great deal ; however, can be done in the way of general prophy- 
laxis. Koch was the first to formulate intelligent rules based on 
the biologic characteristics of the colon bacillus, and in case of a 
threatened epidemic, these measures are of the greatest value. Bac- 
teriologic examination of the stools should be made in all suspicious 
cases and all the patients should be isolated. The stools, the room, 
the linen, everything with which the patient comes in contact 
should be thoroughly disinfected. Isolation should be continued 
during convalescence until the stools are free from cholera bacilli. 
Furthermore the stools of all those individuals who have been in 
contact with cholera patients should be repeatedly examined by 
bacteriological methods, so that one may be quite sure that they are 



106 



INFECTIOUS DISEASES 



Vaccination 



free from cholera bacilli. If vibrios are found, these patients 
should be isolated. The water supply should be examined with care 
and if any suspicion of contamination of the water is aroused, such 
water should be absolutely excluded from domestic use; and all 
water should be boiled during the danger period. 

Vaccination against cholera is very valuable from a prophylactic 
standpoint. In India protective inoculations practised by Haffkine 
have been efficient. Two vaccines are used, Vaccine I being a cul- 
ture attenuated by prolonged growth at 39° C, Vaccine II, admin- 
istered five days later, being a virulent culture. The symptoms fol- 
lowing the subcutaneous injections of these live organisms are very 
insignificant. Kalle used another vaccine prepared by exposing 
virulent cultures to a temperature of 58° C. for one hour. This 
kills the organisms. Just one-half per cent, of phenol is used as a 
preservative. In the Chinese epidemic of 1902, this vaccine re- 
duced the incidence of the disease 10.06 per cent, in the inoculated 
as against 13 per cent, in the uninoculated, and the mortality in 
the inoculated to 0.02 per cent, as against 10 per cent, in the un- 
inoculated. Moreover, the disease, when it occurred in inoculated 
individuals, ran a very mild course. These are the two chief vac- 
cines that have vindicated their claims to usefulness. 

Serum therapy has not been successful in cholera. 



PLAGUE. 



Prophylaxis The discovery by Kitasato and Yersin in 1893-94 of the bacillus 

pestis as the specific organism of plague has furnished us with the 
means of exercising an intelligent prophylaxis against the incidence 
of this epidemic disease and has furnished a method of producing 
temporary immunity by means of a prophylactic serum. 

In establishing prophylaxis against a plague epidemic, bacte- 
riologic examinations of the blood, the fluids taken from a bubo 
and the sputum should be made and the presence or absence of the 
bacillus pestis established. All suspected individuals and all per- 
sons who have been exposed to them should be absolutely isolated. 
The clothing, the excreta, everything that the patients have been 
in contact with — their rooms or whole houses — should be thorough- 
ly disinfected. Fleas and particularly rats should be destroyed. 
Finally prophylactic injection should be given. 

Plague sera The most effective injection is that of Haffkine, which consists 

of a bouillon culture of the bacillus pestis six weeks old, in which 
the organism (growing in stalactite formation) is killed by ex- 
posure to a temperature of 65° C. for one hour. From 0.5 to 3.5 
cc. are used for an inoculation, the dose varying according to the 



INFECTIOUS DISEASES 



107 



size and the age of the patient. It may be necessary to give a num- 
ber of inoculations. Symptoms of only moderate severity follow 
this procedure. During the first few days no protection is offered. 
The immunity, however, finally bestowed generally persists for 
weeks or months. 

Other vaccines of some value have been extensively used. The Vaccines 
German Commission employs an agar culture two days old in which 
the organisms have been killed by exposure to heat of 65° C. for one 
hour. The precipitate formed by acetic or hydrochloric acid from 
a one per cent, potassium hydroxide extract of cultures of the bacil- 
lus pestis has been used as a prophylactic "vaccine" by Lustig and 
Galleotti. There are many other sera, but none of them excel the 
above in efficiency. This protective inoculation presumably bestows 
a certain antibacterial power to the serum, but no antitoxic power. 
It is also probable that the phagocytic action of the leucocytes is 
stimulated and destruction of the bacteria promoted in this way. 

The prophylactic serum is prepared by immunizing horses first 
with killed and then with live cultures. From several months to 
one and one-half years are required for the production of an 
effective serum. An important point that must be considered in its 
preparation is the assurance that the serum is quite free from living 
bacilli. The immunity conferred by the injections of this prophy- 
lactic serum usually extends over about two weeks. It has its par- 
ticular field of usefulness in the pneumonic form of plague and 
repeated inoculations are generally necessary to influence the course 
of the disease. A positively curative effect has so far never been 
obtained. 



Prophylactic 
serum 



STREPTOCOCCUS INFECTIONS. 

The numerous disorders produced by streptococcus infections of Specific serum 
various kinds and the complicating effect of the streptococcus in 
scarlet fever epidemics render the use of streptococcus serum occa- 
sionally indicated. Streptococcus infection produces a temporary 
immunity, which is not of long duration, however. Animals can 
be artificially immunized with filtrates of streptococcus growths, 
with killed or with living cultures. It is much better, however, to 
use for immunization purposes a toxic solution containing bacterial 
cells. Very virulent strains of streptococci produce a serum of a 
much higher protective power than strains of a low virulence. The 
efficacy of the well known sera of Marmorek and Aronson depends 
upon the immunization of horses with streptococci of the highest 
virulence produced by passing these micro-organisms as a prelim- 
inary step through the body of rabbits. 



108 



INFECTIOUS DISEASES 



Multiplicity of 
strains 



Scarlet fever 



Rheumatic 
fever 



Erysipelas 



One of the main difficulties inherent in the satisfactory employ- 
ment of streptococcic sera is the presumable multiplicity of strains 
of streptococci; it remains uncertain to this day whether the same 
streptococci produce the different diseases that are attributed to 
streptococcic infection. The serums of Marmorek and Aronson are 
prepared from a single strain of streptococci, whereas the serum of 
Denys, which enjoys great popularity, is prepared by immunization 
with different strains of streptococci of artificially increased viru- 
lence. The latter serum is called a polyvalent, the former a univa- 
lent serum. Assuming that specific streptococci are instrumental in 
producing many of the complications of scarlet fever, a specific 
anti-streptococcic serum to be used in the treatment of scarlet fever 
has been prepared by Moser by immunizing horses with a number 
of strains of streptococci procured from cases of scarlet fever. In 
the same sense the anti-streptococcic serum that has been used in 
the treatment of rheumatic fever with some success is procured by 
immunization with several strains of streptococci secured from the 
tonsils of patients suffering from rheumatic fever. In neither case 
is an attempt made to increase the virulence of these streptococcic 
strains by their passage through the body of rabbits, as otherwise 
the original biologic properties of the cultures might be modified 
or destroyed. 

Considerable success has crowned the efforts of various investi- 
gators to produce protection in animals with these sera. In the case 
of human beings the evidence is much more conflicting. No dis- 
tinct curative power has ever been established for any of the sera, 
but it has been found that by the employment of such sera the 
course of the disease may be favorably modified, especially as far 
as the temperatures and the general condition of the patients are 
concerned. If, therefore, they are readily available, there seems 
to be no objection to their use and possibly some argument in favor 
of their application. In erysipelas, a supposedly streptococcic in- 
fection, the results have been practically negative from the use of 
streptococcic sera. 



STAPHYLOCOCCUS. 



Autogenous 
vaccination 



The staphylococcus being the most common producer of pus in 
man, it is desirable to have some specific method of immunizing or 
vaccinating against this organism, particularly when the pus in- 
fection appears very intractable and does not yield to the ordinary 
surgical and topical treatment, or if the pus focus is located in a 
region of the body not accessible to surgical interference. Virulent 
infections with the staphylococcus of the skin, the mucous and 



INFECTIOUS DISEASES 109 

serous surfaces, as well as the periosteum are particularly intracta- 
ble and here autogenous vaccination with careful control of the 
opsonic index occasionally produces very gratifying results. 

It has been shown that the serum of an animal recovered from Protective 
a staphylococcus infection or the serum of an animal artificially 
inoculated protects other animals against staphylococcus infections. 
It appears that in the case of the staphylococcus the protective 
power of the serum is due to its power to stimulate increased 

phagocytosis. The method of producing autogenous vaccines in Acne, furuncu- 

losiSc sycosis 
staphylococcus infections, particularly in obstinate cases of acne, 

furunculosis and sycosis is the following: — 

The staphylococcus secured from the infected area is grown in Preparation of 

vaccine 
bouillon for three weeks and then killed by exposure to 60° C. for 

one hour. The vaccine is standardized by determining the number 
of organisms in each cubic centimeter of the bouillon. Huge quan- 
tities of the cocci are used for injection, from twenty-five hundred 
millions to seven hundred millions being used. The quantity is 
regulated by a control of the opsonic index of the patient's serum. 
The proper dose produces a preliminary short negative phase in 
which the opsonins are decreased, followed by a longer positive 
phase in which they are increased. By keeping the opsonic index Opsonic index 
high very good results are often obtained by this method, better 
than by any other mode of treatment so far known. The technic, 
while complicated, is simple enough, if a properly equipped labora- 
tory and assistants thoroughly trained in the routine of this method 
are available. 



ANTHRAX. 

(Malignant pustule.) 

While this disease is particularly prevalent in animals, still an Serum therapy 
occasional case appears in man. In view of the fact that artificial 
immunity against this disease can be created, the occasion may arise 
for this procedure in individuals occupied in handling, for instance, 
a herd of sheep infected with the disease. The immune serum is 
produced by immunizing first with killed or attenuated cultures and 
later with live, virulent bacilli. The serum produced in this way 
acts only as a prophylactic but exercises no effect upon the course 
of the disease, especially after the blood stream contains bacilli. No 
harm, however, can accrue from its use in human beings affected 
with malignant pustule. The serum is prepared in large quantities 
for commercial purposes and can be readily secured. 



110 



INFECTIOUS DISEASES 



COLON BACILLUS. 



Autogenous 
vaccination 



Autogenous vaccination is of great value in many cases of colon 
bacillus infection, particularly involving the renal pelvis, ureter 
and the 'bladder. While absolute reliance cannot be placed upon 
this method, it must be considered a valuable adjuvant decidedly 
worth trying in combination with the other measures that are indi- 
cated. The results from autogenous vaccination in colon bacillus 
infections of the gall-bladder and the peritoneum and the meninges 
and in suppurative processes of the middle ear are very doubtful. 
And in colon bacillus septicemia the results as far as one can judge 
from the literature are essentially nil. 



EPIDEMIC CEREBRO-SPINAL MENINGITIS. 



Causation 



Specific treat- 
ment 



Results 



This disease is most apt to occur in an epidemic form during 
the cold weather and among children deprived of sufficient fresh 
air and sunlight. In other words, unhygienic surroundings and 
"crowd poisoning" must be considered predisposing causes. It 
seems that the common focus of infection is the pharyngeal tonsils, 
the invasion of purulent matter into the base of the brain occurring 
either through the blood channels or the lymph channels. 

The specific treatment of this disease by means of a serum dis- 
covered by FLexner and Jobling in 1908 may be considered one of 
the most brilliant accomplishments of modern medicine, and the 
injection of this serum constitutes the one and chief method of 
treating the disorder. 

Since the introduction of the serum the mortality has been im- 
mensely reduced; besides, fewer chronic invalids are seen among 
those who recover from the acute infection after the use of the 
serum than among those who recover without the serum treatment. 
The duration of the disease, moreover, is greatly shortened by the 
serum treatment. 

Dr. Simon Flexner expresses himself as follows relative to the 
efficacy of his serum : 

"The conclusion may be drawn that the anti-meningitis serum, 
when used by the subdural method of injection, in suitable doses 
and at proper intervals, is capable of reducing the period of illness ; 
of preventing, in large measure, the chronic lesions and types of the 
infections ; of bringing about complete restoration of health, in all 
but a very small number of the recovered, thus lessening the serious, 
deforming and permanent consequences of meningitis; and of 
greatly diminishing the fatalities due to the disease," 



INFECTIOUS DISEASES 111 

The method of using the serum is as follows : — 

Upon the appearance of suspicions symptoms a lumbar puncture Technique 
should be made and, if the fluid obtained is cloudy, serum should 
at once be administered. It is best to withdraw about 20 cc. of 
the spinal fluid and to inject an equal amount of the serum through 
the same needle. These injections should be repeated every day 
until convalescence is manifest, or until four injections are given. 
If the condition of the patient becomes aggravated after the first 
injection, a second one should be given within ten to twelve hours, 
and it is well in these cases to inject a larger amount, i. e., from 40 
to 50 c. c. After four injections have been made, it is best to wait 
three or four days and then to begin another series of injections, 
provided the symptoms still persist. 

In addition to the specific treatment antiseptic treatment of the Antiseptic 
upper air passages should be rigorously instituted. A gargle of 
equal parts of peroxide of hydrogen and water should be used fre- 
quently and the nostrils should be sprayed with a weak alkaline so- 
lution such as DobelPs solution. The eyes should be treated with a 
mild antiseptic, as boric acid solution, particularly if there is con- 
junctival involvement. The intestinal tract should be thoroughly 
cleaned out with calomel, followed by a saline. If there is much 
nausea or vomiting, much pain or a tendency to convulsive seizures, 
morphine should be administered in the proper dose. Here one 
must choose the smaller of two evils. Sleep should also be pro- 
moted by the use of mild hypnotics like bromides or chloral. The 
diet should be liquid or semiliquid and administered in small 
amounts at frequent intervals. 

Ergot has been recommended as a means for relieving the in- Ergot 
flammation caused by the diplococcus and should be administered 
while the serum is being given as a specific. Contraction of the 
blood vessels, as produced by ergot, particularly in the cerebro- 
spinal axis, reduces the nervous phenomenon. It is best given in- 
tramuscularly into the deltoids or the calves of the leg, about 1 cc. 
of a pure antiseptic ergot for a child of ten or over, half a cubic 
centimeter for a younger child, and 2 cc, or an hypodermic syringe- 
ful, to an adult. This same dose should be repeated at three-hour 
intervals for two or three doses, until the desired effect is produced 
and then every six hours until the most acute symptoms of the 
inflammation become allayed. Occasionally ergot injections pro- 
duce a painful local reaction which is easily relieved by a warm, 
wet compress of one part of alcohol to three parts of water. An 
additional advantage of ergot is that it prolongs the action of mor- 
phine, so that less morphine need be given, if the appropriate dose 
of ergot is administered at the same time. 



112 



INFECTIOUS DISEASES 



Venesection 



Hydrotherapy 



Iodides 



If the blood pressure is very high, withdrawal of a small amount 
of blood by venesection or the administration of nitroglycerin may 
be indicated. This, however, will rarely be the case. Alcohol 
should never be administered, nor any of the nerve excitants such 
as strychnia or quinine. 

In order to bring the blood to the surfaces of the body and away 
from the central organs,, appropriate hydrotherapeutic measures 
may be instituted, best of all the warm sponge bath. The head 
should be shaved and kept elevated and the ice-bag applied. 

As soon as the patient recovers the ergot should be stopped and 
some iodide given instead, on the assumption that iodides admin- 
istered for a prolonged period of time and in small doses aid in the 
absorption of any solidifying exudate that may have formed. The 
best iodide preparation is sodium iodide, which should be given in 
doses not to exceed two grains, three times a day, to a little child. 
The treatment of the convalescent period does not differ materially 
from that of any other acute infectious disease. Complications 
and sequelae are treated symptomatically. 



PULMONARY TUBERCULOSIS. 



Spontaneous 
recovery 



Means of 
treatment 



Fresh air 

Rest 

Diet 



Pulmonary tuberculosis in most cases shows a spontaneous tend- 
ency toward cure or latency provided the proper conditions are 
created for recovery. The main object of treatment, if the diag- 
nosis is made early enough, is to secure for the patient ideal sur- 
roundings adapted to the individual peculiarities of the case, to 
grant the patient the maximum of pure air under suitable climatic 
conditions, and to feed, rest and clothe him properly. Medicines 
play a subordinate role in the treatment of pulmonary tubercu- 
losis. There is no specific remedy for the disease (tuberculin, 
creosote, etc., see below) and drugs should be employed only to 
remedy especially distressing or dangerous symptoms and compli- 
cations and, in the late stages, to render the patient comfortable. 

Life in the open air when combined with proper feeding and 
careful regulation of rest and exercise, when carried out in sur- 
roundings and under conditions that favor a cheerful and hopeful 
mood and, above all, when carefully supervised and controlled by 
a competent physician, is the best remedy for the cure of pulmonary 
tuberculosis. It is important to realize, however, that neither fresh 
air alone ? nor over-feeding alone, nor rest alone, can cure tuber- 
culosis of the lung. It is essential that the three elements be com- 
bined. A phthisical patient may live out doors for twenty-four 
hours during each day and still not improve unless his diet is prop- 
erly regulated, and unless he avoids exertion beyond his strength ; 



INFECTIOUS DISEASES 113 

or he may be over-fed and kept in bed and still succumb because 
the supply of fresh air is insufficient and the surroundings remain 
gloomy and depressing. 

Why abundant fresh air aids so materially in the cure of pul- Rationale of 
monary tuberculosis is difficult to understand. Probably the ab- treatment 
sence of tubercle bacilli and of pus germs and other bacteria that 
produce mixed infection is an important factor. The open air, 
moreover, contains a much smaller proportion of the noxious gases, 
notably C0 2 , of body emanations and chemical irritants that soon 
pollute the atmosphere of inclosed spaces. Finally, the ozone of 
out-of-doors, the radiation of the sunlight and, above all, the psy- 
chic stimulus of life near to Nature in open spaces, and the im- 
provement of the appetite that results from an open-air existence 
must all be considered important elements. 

To secure an abundance of fresh air all the year round, in good Advantages of 
weather and in bad, in the heat of summer and the cold of winter, treatment 1 
is a difficult problem. The best conditions are undoubtedly ob- 
tained in a closed institution arranged especially for the care of 
tuberculous patients, and here assuredly the most brilliant results 
are witnessed. Wherever feasible, therefore, the tuberculous patient 
should be advised to enter such an institution. The choice of the 
location, i. e., whether at an altitude or at the level of the sea, 
whether moist or dry, whether hot or cold^ in other words whether 
mountain, desert or sea-shore, must be made according to the gen- 
eral principles to be presently discussed. 

If the circumstances of the patient do not enable him to enter a Home treat- 
private institution of this character, then he should be taught how men 
to secure open-air treatment at home. Also in such cases the sacri- 
fice, pecuniary and otherwise, incident to treatment in a closed in- 
stitution, even if only for a short time, should wherever possible 
be urged. For the educational value of institution life is of in- 
estimable value to such patients, especially in the present state of 
deplorable ignorance and scepticism on the part of the laity in re- 
gard to the curative value of such simple measures as air, food 
and rest. A patient who has spent even a few weeks in a well-con- 
ducted institution soon becomes an ardent and enthusiastic con- 
vert to the open-air idea, for he has been convinced by the good re- 
sults he has seen, by the tales of convalescents he has heard, and he 
has had the benefit of the precepts and the suasion of 
the medical corps in charge. On returning from the insti- 
tution the patient is generally only too glad to co-operate in every 
way with the family physician at home. Above all, he has learned 
to help himself in solving the difficult problem of securing the prop- 
er arrangements at home necessary to continue the plan of treat- 
ment begun in the sanitarium. 



114 



INFECTIOUS DISEASES 



Technique of 
home treat- 
ment 



Room tem- 
perature 
Window tents 



Errors of 
routine 



Disagreeable 
symptoms in 
beginning 
fresh air plan 



Life in a tent placed in the back yard of a city home, or on a 
veranda with southern, southeastern or southwestern exposures, 
generally meets all the necessary requirements during the greater 
part of the year. During the rigid winter months tent life is 
usually unnecessarily uncomfortable and a room can be easily ar- 
ranged in which the windows are kept wide open during the day 
and in which the patient properly clothed (see below) lives all the 
time. The room can be kept at a moderate temperature better than 
a tent. It is well to realize that air can be fresh and wholesome 
without being uncomfortable. During the night any one of the 
numerous window tents that are in the market, or that can be con- 
structed by any carpenter, may be used to enable the patient to have 
at least his head out of doors while the body is warmly covered and 
comfortably tucked away in bed. Here the inventiveness and the 
ingenuity of the physician, patient and friends must secure the 
proper conditions adaptable to the surroundings and circumstances 
peculiar to each individual case ; and it would be a futile and super- 
fluous task in this volume to discuss all the mechanical devices and 
to enumerate all the technical details that have been described to 
render the carrying out of the fresh air treatment of consumption 
practicable. 

In recommending this mode of treatment for cases that are un- 
able to avail themselves of the benefits of the sanitarium plan 
errors of routine are often committed. The physician who merely 
tells his patients to sleep out-doors or to keep the windows open 
all the year round, errs grievously if he contents himself with 
such general phrases ; for it it very important to realize that many 
cases, especially in the beginning of the fresh air treatment, may 
become markedly aggravated unless the effect of the fresh air, espe- 
cially during the cold and moist seasons of the year, is carefully 
controlled. 

One will quite commonly find that, in the beginning, the pa- 
tients complain of irritation of the trachea and bronchi, of dizzi- 
ness, insomnia and a general feeling of discomfort. In some, espe- 
cially during foggy weather, the irritation about the respiratory 
organs often becomes altogether unbearable, so that increased cough- 
ing and severe dyspnea supervene. To insist upon wide open win- 
dows or an out-door life under these conditions is cruel and wrong. 
Such patients should, by all means, be very gradually accustomed 
both to the increased amount of out-door air and to the greater 
moisture and lower temperature of the atmosphere they are forced 
to breathe, and should not be allowed to ignore the disagreeable 
phenomena that make their appearance and to carry out the rigid 
fresh air plan despite of them. Again, most tuberculous cases are 
especially susceptible to draughts ; this is due to the fact that tuber- 



INFECTIOUS DISEASES 115 

culosis is often accompanied by anemia and profuse sweating. Such 

patients are very apt to catch cold in the beginning of the fresh 

air treatment and, in this way, to have their condition seriously 

aggravated. 

It often becomes necessary, therefore, as a preliminary to the Hardening the 

D3.ti.cnt sis si 
continuous fresh air treatment, to subject the patient to a carefully preliminary 

regulated hardening process according to the principles that have 
been discussed in full in the Sections on Anemia and Acute Rhi- 
nitis. For practical purposes the following method is very useful, 
not disagreeable, and, above all, never dangerous to the patients. 
The skin, in the beginning, is treated once or twice a day by dry 
rubbing under covers with a rough cloth or the hand. Later the 
surfaces of the body are treated with alcohol, then with alcohol and 
water and later with water that should be lukewarm at first and 
gradually used cooler and cooler until finally the patients can be 
sponged with water of room temperature. The sponging should be 
carried on under blankets, one extremity, the abdomen, back, chest 
being treated at a time, and should be followed by a brisk alcohol 
rub. Still later the patient may be treated once a day by wet packs 
of room temperature, in such a way that the whole body is quickly 
wrapped in a linen cloth wrung out of cool water and covered with 
a woolen blanket. They are allowed to remain in this pack only 
from three to five minutes. The surface of the body is then rubbed 
dry with a rough towel and treated with alcohol. 

In this way the superficial capillaries are educated to react more 
energetically to sudden temperature changes and the tendency to 
catching cold is materially reduced. At the same time the respira- 
tion, circulation and the general metabolism are greatly stimulated. 

While this hardening process is being carried out, it will usu- Intermittent 
ally be necessary to render the fresh air treatment intermittent, 
that is, to have the patients in the open only during certain hours 
of the day when the sun is shining and to have the windows open 
altogether only on days and nights during which the weather is not 
too cold or foggy, and only partially open on stormy days or nights 
with rain^ snow, or violent winds. In such weather the patient 
should be carefully protected from the wind by a screen or some 
other protective device. 

The clothing of tuberculous patients undergoing the fresh air Clothing 
treatment should be regulated according to the temperature of the 
air. During warm weather flannel underwear that absorbs the 
moisture from the skin and allows its slow evaporation; during 
cold weather wool garments should be worn. Silk or linen under- 
wear should never be allowed, for it clings to the skin and in this 
way obliterates the layer of immovable air that should intervene 
between the body surfaces and the first garment. A sufficient num- 



116 



INFECTIOUS DISEASES 



Choice of 
climate 



When to send 
patients away 
from home 



ber of woolen blankets should be used to keep the patient comfort- 
ably warm; on top of them furs may be placed, but furs should 
never be worn about the neck. A cap made of wool may be used 
to protect the head and ears during the night, and hot water bags 
may be placed to the feet. It is a very important rule not to have 
the clothing about the chest too tight fitting in order that the re- 
spiration may not be impeded. 

Inasmuch as life in the open air is one of the most important 
factors in the cure of tuberculosis, the choice of a climate for tuber- 
culous patients becomes a matter of serious import. The ideal cli- 
mate by all means is the one in which the patient can enjoy the 
maximum of out-door life with the least discomfort. 

Above all, the physician who sends his tuberculous patients 
away from home in order to give them the benefits of another cli- 
mate should consider the circumstances and the accustomed mode of 
life of the patient at home, and should compare them with the en- 
vironment the patient will be forced to live in at the resort to 
which he is sent. If the case is very far advanced, or if the patient 
is in very moderate circumstances, it is usually a cruel undertaking 
to send him away from home and friends, away from the physician 
in whom he has confidence, into strange surroundings, among 
strange neighbors and to a strange physician. It is well to remem- 
ber that climate alone can impossibly cure a case of tuberculosis 
unless the diet and the general mode of life are carefully regulated 
and unless the mood of the patient can remain at least as cheerful 
as it was at home. It is pitiable to see advanced cases of tubercu- 
losis arriving at resorts for tuberculosis and eking out a miserable 
existence at a boarding house where they are shunned like lepers 
(provided they are admitted at all) ; eating worse food than they 
received at home and living the lives of outcasts among unsym- 
pathetic strangers. Whoever has seen these poor sufferers sitting 
dejectedly on the curb in the broiling sun of a desert village, under- 
fed, over-exerted, helpless and thoroughly miserable, can hardly 
suppress a feeling of indignation at the almost criminal stupidity 
of those who are responsible for placing the unhappy exiles in such 
a position. It is a thousand times better that such cases should 
remain at home, even in a city and in a cold climate. 

Provided, on the other hand, the patient's means permit him 
to secure the proper accommodations and diet and good medical su- 
pervision at the resort to which he is sent, then the climatic con- 
ditions that will most benefit the patient must be carefully consid- 
ered. Two climates in particular enjoy deserved popularity in the 
treatment of tuberculosis, namely 9 mountain climate and Southern 
climates. Both have their advantages and their contra-indications. 



INFECTIOUS DISEASES 117 

Some cases do best at moderate altitudes, others at the sea-shore or 
on an ocean steamer, some in the desert where the air is dry, others 
inland where the air is warm and moist. It would lead altogether 
too far to discuss in detail all the indications for the choice of cli- 
mate as they arise in each individual case, especially as these indi- 
cations vary with changes in the condition of the patient. The 
following general rules, however, may serve as a guide in the selec- 
tion of a climate for tuberculous patients.* 

Best of all for cases of tuberculosis is mountain climate. Here Altitude 
we have low air pressure, comparatively low temperature, slight climate" 1 
fluctuations in the daily temperature, dry air, an atmosphere that 
is flooded with sunshine, that is pure and full of ozone and that 
contains no tubercle bacilli and few pus germs or other bacteria. 
The rarefied air exercises a beneficial influence upon respiration and 
circulation, by forcing the patient to breathe more deeply it alters 
the composition of the blood, stimulates metabolism, promotes the 
action of the skin, increases the appetite, and usually induces sound 
sleep, often, however, only after a period of several days or a week 
of insomnia. 

There are^ however, distinct contra-indications to choice of a Contra-indi- 
mountain climate in tuberculous patients. Cases in an advanced mountain 
stage of anemia; cases suffering from continuous fever; cases with climate 
empyema, pleurisy or pneumothorax, or with laryngeal ulcerations ; 
and patients with valvular heart lesions should be warned against 
life at an altitude. 

The best time to send tuberculous cases to an altitude is in win- . Hi S h . altitude 
ter. While it is very cold in the mountains the air is dry and there summer 
is rarely much wind, hence the cold is not so preceptible as in lower 
altitudes; the clear skies and abundant sunshine and the absence 
of much fog or mist, moreover, render a sojourn in mountain re- 
sorts more pleasant and more beneficial than in warmer regions in 
the valleys or the plains. In the heat of midsummer, too, high alti- 
tudes are not useful for obvious reasons. During the Spring and Moderate alti- 
Autumn it is best to send patients to moderate altitudes rather than a " d e a utumn 
to high altitudes. This applies particularly to those who are sent 
to a resort for the first time in spring or autumn, for here sojourn 
at a moderate altitude, not to exceed 3,000 feet, for a time forms 
a beneficial transition to life at a higher altitude during the com- 
ing winter or summer months. 

Life at a low altitude or at sea level may be considered indif- 
ferent as far as its effect upon the human organism is concerned. 
Here the temperature, the amount of sunshine and, above all, the 
amount of moisture in the air are the determining factors. Broad- 
ly speaking a dry climate at sea level has a mildly stimulating ef- 

*See also Climate in "Valvular Diseases of the Heart." 



118 



INFECTIOUS DISEASES 



Low altitude 
Dry, warm 
climate 
Desert climate 



Low, moist 
climate 



Seashore and 
island climate 



Rest 



Exercise 
Walking 



Hill climbing 



feet, whereas a moist climate at sea level has a mildly sedative 
effect. 

A dry warm climate at a low level is especially useful in tuber- 
culosis if there is an abundant secretion from the bronchi; such 
patients do especially well, as a rule, in a desert climate where 
there is also abundant sunshine and where the air is essentially free 
from pus germs. The latter element is very important, for most 
cases suffering from profuse expectoration are afflicted with a mixed 
infection. Life in the desert on account of the absence of pus 
germs in the air often aids materially in converting such a mixed 
infection into a simple tuberculous infection. This is an exceed- 
ingly desirable effect. High mountain climate shares this advantage 
with the desert and mid-ocean. 

To the category of low, moist climates belong chiefly sea-shore 
and island climates. Here the air is pure, contains a large propor- 
tion of oxygen, considerable moisture and salt, and a small amount 
of carbon dioxide. The moisture of the air and the salt it contains 
exercise a mildly stimulating effect upon the bronchial mucosa 
and the skin. The low pressure strengthens and retards the heart's 
action and induces deep, slow respirations. Appetite and sleep are 
usually improved in these climates. Very anemic patients, how- 
ever, rarely do well at the sea-shore, for reasons that have been 
fully discussed in another section. 

Best is an element that is of the greatest importance in the 
treatment of tuberculosis. Consumptives, in the beginning, espe- 
cially if they are suffering from a recent tuberculous infection with 
high fever, immaterial whether they live out of doors or in, should 
be kept absolutely at rest and quiet, i. e. ; they should remain all 
day and all night in a recumbent or a semirecumbent position. 
This also applies with particular emphasis to cases of tuberculosis 
that have had one or more attacks of hemoptysis or are very anemic. 

As soon as some improvement has occurred and the tempera- 
ture is low or normal (the sputum free from blood and the anemia 
improved) the patient should be allowed to walk on the level for a 
little time once or twice a day, beginning with short walks of not 
more than ten or fifteen minutes; they may then gradually be al- 
lowed to increase the amount of exercise according to the reaction 
they show. Shortness of breath, palpitation, dizziness, sweating 
are all danger signals indicating that the amount of exertion is too 
great. A tuberculous patient should never be allowed to exercise 
to this point. Later, as the improvement continues, very gradually 
controlled hill climbing may be permitted. In some resorts a reg- 
ular Oertel-Terrain* system is arranged and the amount of exercise 



*S£e page 279. 



INFECTIOUS DISEASES 119 

carefully regulated by this means. While walking the patient should 
breathe deeply and with great regularity, an object that is best 
accomplished by instructing him to take a deep breath through 
the nose with each step. 

In selecting the diet for a tuberculous patient an attempt at Diet 
over-nutrition should always be made. Mathematically expressed, 
a sufferer from tuberculosis should receive instead of the ordinary Over nutrition 
thirty to thirty-five calories per kilo each twenty-four hours at 
least forty-five calories. In well managed institutions the regula- 
tion of the diet is carried out according to calorimetric methods. In 
private practice and in most resorts feeding, owing to the diffi- 
culty of carefully performing metabolic studies, is generally car- 
ried out according to empiric rules, some of them very crude, very 
one-sided and very wrong. 

The tastes and idiosyncrasies of the patient should always be The diet 
very carefully considered and every endeavor should be advanced to | t able 
render the diet palatable and agreeable. One of the most serious Forced feeding 
obstacles encountered in the forced feeding of tuberculous cases is 
the lack of appetite and the aversion to food (see below) that so 
many of these patients develop after a time. To avoid this is a 
fine art which should be cultivated. The diet should not be too one- 
sided nor monotonous^ but should incorporate the greatest variety 
of food, prepared in a tempting form, preference, of course, being 
given to those articles of diet that possess the greatest nutritive 
(caloric) values. 

The chief article of diet should^ by all means, be meat, for it is Meat 
a well known fact that carnivorous animals and people living on 
an abundant meat diet are much less susceptible to tuberculous in- 
fection than herbivorous animals and vegetarians. At the same 
time, abundant fat should be supplied in the form of cream, butter, Fat 
bacon, olive oil in salad dressing or in mayonnaise, sardines, etc. 
In selecting meat those varieties containing abundant fat should 
be given the choice ; and the meats should be prepared with plenty 
of fat. 

Eggs are a very valuable article of food and a convenient vehicle Eggs 
for supplying abundant nitrogen. They are best eaten either boiled 
or poached or in soups, sauces or omelets, or as an addition to milk 
as egg-nog. There is no particular advantage, a popular prejudice 
to the contrary notwithstanding, in using them raw. In some 
institutions enormous quantities of raw eggs are administered as a 
routine, with the result usually of thoroughly disgusting the pa- 
tients so that they cannot take eggs at all after a time, and with- 
out doing them any particular good that could not be obtained by 
having them prepared in a more tempting form; for no article of 



120 



INFECTIOUS DISEASES 



Milk 



Fruits and 
vegetables 



Beverages 
Alcohol 



Specific treat- 
ment 



Tuberculin 



food can be made more palatable, and prepared in more different 
ways, than eggs. 

Milk is also a very useful article of diet and should be used lib- 
erally in the preparation of vegetables, sauces, gravies, etc. As a 
food between meals milk is also very useful, especially in the form 
of egg-nog or milk-cream mixture (two-thirds milk, one-third 
cream, one tablespoonf ul of lime water) . Many people have a dis- 
tinct aversion to milk and it is worse than useless to try to force 
them to drink it. Occasionally one can accustom patients to milk 
by serving it in small quantities and very cold, or with a little 
brandy. An attempt should always be made to do this. Some 
patients can drink milk without distaste but complain of a feeling 
of satiety even after taking small quantities, so they are utterably 
unable to swallow anything else with relish. In these cases, too, 
the administration of milk should be avoided or greatly curtailed, 
as otherwise over-nourishment of the patient becomes impossible. 

Fruits and vegetables of any kind are allowed, preference being 
given to vegetables containing large quantities of albumen, as peas, 
rice, beans, etc. Plenty of milk, cream, butter, flour should be used 
in preparing all vegetable dishes. 

Of beverages, cocoa, chocolate, tea, coffee, bouillon, broths, meat 
extracts, buttermilk are all useful. Alcohol, too, is a food which 
should not be omitted from the bill of fare of tuberculous cases. 
It is best given in the form of dilute spirits or claret, or light wines 
diluted with water. Beer, owing to the percentage of carbohydrate 
it contains, is a particularly useful beverage and may be taken with 
impunity. It is especially useful in the evening on account of its 
slight soporific effect. Brandy or whisky as an addition to egg- 
nog is also useful. Strong alcoholic liquors, like straight whisky 
or brandy, should be avoided, especially in cases suffering from 
tachycardia or ulcerative processes in the larynx or digestive tract. 
That there are occasionally distinct contra-indications to the use of 
alcohol, especially in sufferers from cardio-renal disease and arterio- 
sclerosis, need hardly be emphasized. 

Medicament ous Treatment. The treatment of tuberculosis with 
products made from the tubercle bacillus, i. e., tuberculin and its 
various congeners, is still to be considered as in an experimental 
stage. Clinicians who have worked for years with these products 
report results that are greatly at variance, some claiming good ef- 
fects in all cases, others indifferent effects in most cases. In resorts 
in which the use of tuberculin and similar products is combined 
with rest, proper feeding and an out-door life the results seem to 
be fairly good, but here it is very difficult to determine how much 
of the benefit is to be attributed to the rest, the diet and the fresh 
air, and how much to the "specific" remedy. 



INFECTIOUS DISEASES 121 

From what experience I have had with this remedy in hospital 
practice and from what I can glean from the literature, I am 
inclined to think that tuberculin possesses some curative value if 
properly used; but that this substance is also very dangerous un- Curative value 
less administered in very small doses and under very careful con- 
trol.* Tuberculin should be used in small doses, so small that no Dosage 
reactive symptoms (i. e., fever, signs of local irritation in the af- 
fected area, general lassitude, headache, pain in the joints, etc.) 
appear. The dose may be gradually increased until these symptoms 
appear and then it should be immediately reduced and the patient 
kept on a quantity slightly below that at which a reaction occurred. 
It is manifestly a difficult matter to determine the onset of a "re- 
action" in a febrile patient, so that this index is useful only in 
quiescent cases. Here a latent tuberculous process may be rekindled Dangers of 
by the injudicious use of tuberculin for therapeutic or for diagnos- 
tic purposes so that at best the remedy is dangerous. Moreover, 
quiescent cases usually get along very well with proper hygiene and 
without specific medication with tuberculin, so that the remedy in 
those cases precisely in which it could be used with some prob- 
ability of success is not only dangerous in careless or unskilled 
hands but also superfluous. 

TUBERCULIN THERAPY. 

In view of the complex clinical picture, the long duration, the Tuberculin 
tendency to spontaneous remissions and exacerbations, as well as to treatment 
spontaneous recovery that is noted in this disease, it is an exceed- 
ingly difficult matter to determine the value of specific tuberculin 
treatment. Following the original announcement of Koch and the 
disasters that resulted from the unscientific and promiscuous ap- 
plication of the early tuberculins a profound prejudice was gen- 
erated in the minds of the profession and the laity against the use 
of the specific products of the tubercule bacillus in the treatment 
of tuberculous infections. Within recent years, however, a reaction 
in favor of tuberculin in the treatment of tuberculosis has set in 
and this method of therapy is becoming more popular every year. 

It is impossible from a small number of cases to draw any 
definite conclusions in regard to the efficacy of this method of treat- 
ment. The only criteria are the results obtained in a very large 
number of cases treated under the same external conditions by 
skillful and well trained hands, together with a study of cases for 
control approximately in identical stages of the disease suffering 
from identical types treated under similar conditions without tuber- 
culin. Many of the favorable statistics that have emanated from 



•The new method of determining the opsonic index has rendered 
the use of tuberculin much more safe and accurate. 



122 



INFECTIOUS DISEASES 



Results of 
Dr. A. L. 
Trudeau 



different institutions suffer from this fundamental defect that they 
were selected cases and that comparisons were not made for con- 
trol with similarly afflicted patients in the same institution. 

The main index of results obtained is the influence of tuber- 
culin injections upon the fever, the pulse rate, the expectoration, 
the disappearance of bacilli from the sputum and the tendency to 
relapse. The condition of the patients at discharge must be care- 
fully noted and the ultimate results at the expiration of two or three 
year» ? as well as the total mortality carefully included in the calcu- 
lation. I have secured from the Adirondack Sanitarium of Sara- 
nac Lake, N. Y., under Dr. A. L. Trudeau, the Pottenger Sani- 
tarium of Monrovia, Cal., under Dr. F. ML Pottenger, the Ottawa 
Tent Colony, of Ottawa, 111., under Drs. Pettit and the Winyah 
Sanitarium, of Asheville, North Carolina, under Drs. von Euck, 
the following expressions of opinion in regard to the results ob- 
tained in these institutions with and without tuberculin. I hereby 
quote as follows from personal communications courteously sub- 
mitted to me over the signature of the above named physicians : 

Dr. A. L. Trudeau of the Adirondack Cottage Sanitarium 
writes : 

"Tuberculin injections have been used without interruption in 
selected cases at the Adirondack Cottage Sanitarium since Koch 
first proposed the treatment. I have found the treatment bene- 
ficial in early cases, and in the chronic apyretic types of the dis- 
ease, even where the pulmonary lesions are quite extensive and of 
long standing, provided the nutrition is good and little or no fever 
is present. The use of tuberculin is inadmissible and generally 
injurious in all active types of the disease which are characterized 
by any marked degree of fever. In such cases tuberculin seems only 
to add fuel to the flames, aggravates all the symptoms, and may 
even, if persisted in, bring about an extension of the lesions. 

The method employed has been the exhibition of very small 
doses, and such a gradual increase in dose at such intervals as to 
avoid as much as possible focal and general reactions. No rule 
can be laid down as to the initial and final doses, the interval be- 
tween the injections, or the rate of increase, as tuberculin sus- 
ceptibility varies within the widest range in each patient. The in- 
itial dose, however, should be so small and the increase so slow as 
to avoid focal and general reactions, and the duration of the treat- 
ment may be from six to twelve months or more, according to the 
indications and progress of the case. No attempt should be made to 
reach any special dose. The highest dose that the patient can be 
brought to tolerate without producing the usual reactionary symp- 
toms is the proper dose for the patient, whether this be only a frac- 
tion of a milligram or 100 or more milligrams. 



INFECTIOUS DISEASES 128 

The results depend greatly on the skill and care with which 
the tuberculin is administered. The various tuberculins all seem 
to contain the same poison. That is, a poison which produces in 
tuberculous individuals the same characteristic symptoms of focal 
and general reactions. Koch thought that B. E. — Bacillen Emul- 
sion — which was the final result of his years of labor in this direc- 
tion, was the best preparation of tuberculin which it was possible to 
produce; but in practice it has not seemed to be better than either 
0. T., the old tuberculin, or B. E., the filtered bouillon in which the 
bacilli have grown and from which they have been filtered off. I 
have always preferred the B. F., because no heat is used in its 
preparation as in the manufacture of 0. T., and it must therefore 
contain all the toxins produced by the growth of the germ or de- 
rived from its body, entirely unaltered by heat, and because it 
gives quite as good results as B. E., is more easily absorbed, and 
produces less often unlooked-for reactions. 

It is evident that the use of tuberculin in pulmonary tubercu- 
losis therefore is a limited one, for it is applicable only to the 
chronic and apyretic types of the disease, whether incipient or ad- 
vanced, and it is inadmissible in that large class in which the dis- 
ease is actively progressing. It has seemed to be also very useful 
in patients who, having been treated by the climatic and open-air 
method, have practically lost their fever but cease to make any 
more improvement, and have occasional relapses. In such cases the 
tuberculin treatment will often carry the patient to a more or less 
complete and permanent arrest of his disease. 

Tuberculin does not produce immunity to tuberculosis clinically 
or experimentally, but it acts like most vaccines by stimulating the 
defensive resources of the system and thus enabling the patient to 
overcome his infection. The last word about tuberculin treatment, 
however, it seems to me, has not yet been said, for we have very lit- 
tle accurate knowledge as yet of the poisons of the tubercle bacillus 
and their variation in virulent and attenuated cultures, and it is 
not impossible that the tuberculins thus far obtained artificially con- 
tain only an altered toxin, or only one of the toxins which enable the 
bacillus to spread its infection through the living organism. I feel 
that by improved chemical and cultural methods a better tubercu- 
lin will be forthcoming — one which will not be so likely to bring 
about intense inflammatory reactions in the lesions and will there- 
fore be applicable to that wide range of cases which are progress- 
ing more or less rapidly and where fever is still present in spite of 
the rest and open air method." 



124 INFECTIOUS DISEASES 

Dr. F, M. Pottenger of the Pottenger Sanitarium, Monrovia, 
Cal., reports as follows: 

Results of Dr. "After observing the treatment of tuberculosis of the larynx for 

enger many years, and seeing its beneficial effects in these unfortunate and 
serious complications, I have become absolutely convinced that tu- 
berculin when administered right is of great value in the treatment 
of tuberculosis. No less convincing has been the effect produced 
upon the disease within the chest, as determined by the stethoscope. 
The results in the Pottenger Sanatorium, where we treat large- 
ly third stage cases, have been very satisfactory. We have secured 
apparent cure of about 87 per cent, in first stage cases, 60 per cent, 
in second stage, and 10 per cent, of third stage, with an arrest- 
ment of about 25 per cent, in the second stage, and about 28 per 
cent, in the third stage. I do not attribute this wholly to tuber- 
culin — I attribute it to the general policy pursued, which is one of 
individualization and close personal supervision. But I do be- 
lieve tuberculin has added greatly to the results obtained. 

No two patients can be treated alike with tuberculin; the rem- 
edy must be suited to the patient, to the peculiar character of his 
disease and to its particular localization; the dosage cannot be in- 
creased according to rule, but must be increased according to the 
patient's reactive powers, which can soon be determined by the ob- 
serving physician ; the time between doses must also vary with dif- 
ferent patients, and according to the dosage employed; by such a 
method alone can the best results in the employment of tuberculin 
be produced. 

Results of Dr. Pettit reports from Ottawa, 111. : 

Drs. Pettit "The percentage of incipient cases cured and benefited in the 

tuberculin treated group is about the same as in the untreated. 
However, the percentage of deaths in the untreated is over twice 
thai? in the tuberculin treated group. In the moderately advanced 
stage the tuberculin treated cases show a marked advantage both in 
the percentage of cured and improved, and the percentage of deaths 
in the tuberculin treated group is very much less than in the un- 
treated. The number of cases in the far-advanced stage — in both 
the treated and untreated groups — is too small for comparison, but 
from the cases recorded it can be seen that little in the way of the 
treatment can be done for cases in the far-advanced stages. 

"A study of the number of deaths occurring from eighteen 
months to six years after discharge from the institution is also verv 
interesting. The total number of deaths occurring in the tuber- 
culin treated cases is 22 per cent, less than in the group of cases 
treated without tuberculin. This sort of a statistical study is sub- 
ject to many limitations — difficulty in tracing cases, looseness in 
classification of cases and results — and is open to criticism from 



INFECTIOUS DISEASES 125 

many angles, but in the absence of convincing evidence from other 
sources, immunological studies, animal experimentation, observation 
of clinical phenomena and other fields of more accurate study, the 
present method of study is justified and the results, while not abso- 
lutely conclusive, are to me convincing and support the view that 
tuberculin is already of therapeutic value in the treatment of pul- 
monary tuberculosis, especially in cases in the moderately advanced 
stage, that it is not harmful, assists in the cure and protects against 
relapse." 

Drs. von Euck of Asheville, North Carolina, report as follows : Results of 

"We believe that the therapeutic value of tuberculin depends Drs * von Ruck 
upon conferring artificial bactericidal immunity. The presence of, 
as also the degree of said immunity, we can determine at present 
only by finding in the serum of treated patients immune bodies and 
by determining their amount. 

We are not unmindful of the fact that other evidence of im- 
munity may eventually become demonstrable to our senses, only at 
this time the methods of determining specific agglutinins, precipi- 
tins, power of binding complement (amboceptor) and opsonins are 
all that we have to guide us in the question of the action of reme- 
dies designed to accomplish specific resistance to related bacteria. 

In our studies of the different tuberculins in this light we have 
found that they can be divided into two groups, viz. : One group 
representing the original tuberculin and all its modifications. The 
other group being represented by products obtained from the tuber- 
cle baccilli themselves. The characteristic feature of the first group 
is that all these tuberculins are made from culture fluid upon 
which tubercle bacilli have been grown and the differences in the 
several preparations of this group, as regards the production of 
immune bodies, depend upon the age of the cultures used and the 
manipulations in manufacture, by and through which more or less 
extractives or autolytic products of the bacilli enter into solution in 
such culture fluids. 

In the second group the culture fluid forms no part. Here we 
have the tubercle bacilli emulsions, the glycerin extracts and the 
watery extracts of tubercle bacilli. We have found that the emul- 
sions are less desirable when made from tubercle bacilli that have 
not been prepared by first extracting their fats and waxes in so 
much as they are apt to cause local irritation and necrosis and in 
any case emulsions act more slowly and at times cumulatively. This 
is to be expected from an emulsion in which besides fragments of 
bacilli, whole bacilli and even clumps of them may be found on 
microscopic examination. 

Watery extract from bacilli deprived of fats and waxes yield a 
large amount of proteins and, if heat above 50° C. be avoided, 



126 



INFECTIOUS DISEASES 



they contain proteids not at all obtainable in preparations of group 
one or in glycerin extracts. This watery extract is the prepara- 
tion which we use clinically, although we have known for a long 
time that it does not carry the proportionate amount of nucleopro- 
teins which it should, if all proteins were equally extracted; and 
we have only recently succeeded in accomplishing this to such a 
degree that we can now say that all the proteins of the tubercle 
bacilli are present in normal proportion. 

From the watery extract as used at present, there have been no 
accidents nor any untoward effect in its clinical administration. 
The increase of immune bodies is better marked, occurs more rap- 
idly and reaches in time higher degrees than we have been able to 
observe from Koch's or our own emulsions. Our immediate clinical 
results, as well as their observed permanency exceed those of any 
other reported work. We likewise find that examinations of serum 
from one to fourteen years after discontinuance of treatment, still 
show the presence of such immune bodies, as a rule in much larger 
amounts than do sera of cases which have not been treated, or of 
such cases in which preparations of Group 1 have been used. 

The clinical results accomplished in 292 cases of pulmonary 
tuberculosis treated in 1909 and 1910 qualified by stages with the 
average duration of treatment may be noted in the following table. 





General. 


App 


Recovered. 


Gr'tly Impr'd. 




2 


hd 


$> 


2 


* 


$5 


3 


I? H|> 




d 
3 


CD 




d 

3 


CD 


3 < 

P HJ 


c 
B 


CD "-J <J 

p -j 




c 


Q 


£§ 


o 1 


o 


CD fSX 


a" 


a ££ 


STAGES. 


CD 


cd 
d 


CD 


CD 

d 


S-S 


CD 
1 


3 % 








. P 
• *< 






• u 
: p 
: «<* 




. 03 


Class A— I Stage 


73 


25 


118 


67 


91.8 


124 


5 


6.8 91 


Class B— II Stage. . . 


. 113 


38.7 


154 


68 


60.2 


187 


20 


17.8 161 


Class C— III Stage... 


. 106 


36.3 


143 


33 


31.1 


204 


22 


20.8 172 


Total 


.. 292 100 141 
Improved. 


168 57.5 155 
Stationary. 


47 
Pr 


16.1 165 




ogressive. 




2 


hd 


$> 


2 


§■** 


$> 


SS 


5 ^ 




d 
B 


cd 


2 < 


d 

3 




g£ 

P t-1 


d 

3 


cd n <j 
P >-i 




o* 


O 


&3 


c 


I o 


r+ 6} 


o* 


O £P 


STAGES. 


CD 
4 


cd 
d 


CD 


,.. CD 
1 d 


CD 


§ 2,3 






e* 










<-»■ 








: o 




m • 


: d 




: : o 








: p 




K; * 


: p 




: : p 








: v* 




E?j • 


. «j 




: vj 








. m 




& . 


. W 




. 33 


Class A — I Stage 


1 


1.4 


39 

















Class B— II Stage 


. 12 


10.6 


60 


2 


1.7 


60 


11 


9.8 54 


Class C— III Stage 


24 


22.6 


94 


3 


2.8 


61 


24 


22.6 88 


Total 


.. 37 


12.8 


81 


5 


1.8 


60 


35 


11.8 77 



A general summary for all cases treated in the Winyah Sani- 
tarium since 1888 appears on page 11 of the bi-annual report from 
the Institution for 1907 and 1908. 



INFECTIOUS DISEASES 127 

This shows for all stages as follows : 

782 cases treated without the addition of specific remedies to 
the usual methods. 

Apparently recovered 11.0 per cent. 

Improved 30.5 per cent. 

Stationary or progressive 57.6 per cent. 

723 cases with addition of specific remedies, the preparations 
belonging to Group oeo. Chiefly old tuberculin and modifications 
thereof : 

Apparently recovered 36.8 per cent. 

Improved : . . 42.8 per cent. 

Stationary or progressive 20.4 per cent. 

1503 cases with addition of specific remedies, the preparations 
belonging to Group 2 ; chiefly watery extract of tubercle bacilli : 

Apparently recovered 55.5 per cent 

Improved 33.8 per cent. 

Stationary or progressive 10.7 per cent. 

In this total of over 3,000, the percentage of early stage cases 
varied in different reports between 20 and 30 per cent. 

The report for 1905 and 1906, contains also a tabulation by 
stages as to the endurance of the results after from 2 to 10 years, in 
comparison with those shown on discharge, permanent results being 
shown and the patient having remained in good health : 
For early stage cases discharged as cured or improved. 91.4 per cent. 
For second stage cases discharged as cured or improved 80.4 per cent. 
For third stage cases discharged as cured or improved. 37.4 per cent. 
For all stages 68.8 per cent. 

The same report gives an exhibit of the reported results of 
other physicians who had in a clinical material of 2,183 cases in 
all stages employed the same preparation which was used in the 
Winyah Sanitarium and which shows that of the number given 
were: 

Apparently cured 50.3 per cent. 

Improved 29.4 per cent. 

Stationary or progressive 20.3 per cent. 

It appears thus that we are justified in the position which we 
have advocated since the first introduction of tuberculin, that the 
combination of specific treatment with other approved methods is of 
great value in the treatment of tuberculosis, and that especially in 
cases of phthisis in the earlier stages the results are incomparably 
better. A comparison of our clinical results from the use of old 
tuberculin and modifications and from watery extract of tubercle 
bacilli shows the superiority of the latter and confirms our findings 
in blood studies, that the proteins obtained from the bacilli them- 



128 



INFECTIOUS DISEASES 



Creosote and 
its derivatives 



Mode of action 



Effects 



Contra-indica- 
tions to creo- 
sote 



Dose and ad- 
ministration 



selves rather than those obtained from culture fluids, are valuable 
for the production and increase of immune bodies in the patients' 
serum." 

A remedy that has for many years enjoyed popularity in the 
treatment of tuberculosis is creosote and its derivatives, guaiacol, 
creosol and cresol. While this remedy can, in no sense, be con- 
sidered a specific, it certainly does good in most cases of tubercu- 
losis and its use is therefore to be recommended. 

Its exact mode of action is difficult to explain. It can hardly be 
said to possess specific anti-bacterial action against the tuberculosis 
germ, for animals treated with creosote and subsequently tubercu- 
lized succumb to the infection as readily as animals that have not 
previously been treated with creosote. Again, the sputum of tu- 
berculosis cases, that have received large doses of creosote for a 
long period of time, contains as many and as virulent tubercle 
bacilli as that of patients who have not received the benefits of 
creosote treatment. 

However obscure its pharmacological action may be, we know, 
clinically, that it increases the appetite, improves gastric and in- 
testinal digestion and aids assimilation, hence improves the general 
nutrition and increases the strength of the patient; that in most 
cases it relieves the cough, reduces the fever and stops the night 
sweats. The remedy is particularly useful in early stages, but it 
should also be given a fair trial in advanced cases. 

There are distinct contra-indications to its use. Some indi- 
viduals are altogether intolerant to the drug and react to the ad- 
ministration ? even of small doses, by severe signs of intoxication, 
notably violent gastro-enteritis with vomiting and purging, dizzi- 
ness, fainting and profuse sweats. Upon the appearance of such 
symptoms the administration of the drug should, of course, not be 
insisted upon. In other cases the symptoms of creosote intoxica- 
tion are less severe and manifest themselves by milder symptoms of 
gastric and intestinal irritation, such as burning in the epigastrium, 
belching, loss of appetite, slight colic and diarrhea. In many cases, 
as the patients become accustomed to the use of the drug, these 
symptoms disappear, so that the administration of small doses may 
for a few days be tentatively continued intermittently, in the hope 
that the patient will gradually tolerate the remedy. The slight dis- 
comfort from the stomach arising during this trial can well be 
borne in view of the benefits to be expected from creosote if it can 
be taken at all. 

Many preparations of creosote and its derivatives have been 
recommended. If creosote itself is to be taken, it is best given by 
mouth in gelatin capsule with a little cod liver oil, for instance : 



INFECTIOUS DISEASES 129 

Creosotis, 0.1 

01. jecoris aselli, 0.3 

M. One hundred such capsules, 
Sig. Five to ten capsules daily at meal time. 
Or the creosote may be given in wine, as follows : 

Creosotis, 13.5 

Tinctura gentianae, 30.0 

Spiritus vini, 250.0 

Sherry qs. ad., 1,000.0 

M. S. Two tablespoonfuls after each meal with 
a little water. — (Bouchardat and Girribert.) 
Or it may be given in five to ten drop doses in a tablespoonful 
of cod liver oil several times a day ; or by rectum in a milk or milk- 
egg enema, in such a way that thirty drops of creosote are dis- 
solved in 300 c.c. of warm milk to which are added one egg and a 
few drops of opium. 

Two preparations of creosote that, in my experience, are better Creosotal 
than creosote are creosotal and thiocol, the former being a yellow- loco 
ish liquid that is non-irritating and non-toxic (excepting to patients 
with an idiosyncrasy to creosote) even when given in large doses. 
It is given in drop doses in milk or water, beginning with twenty Dose and ad- 
drops three times a day and increasing the dose to a tablespoonful ministration 
three times a day during meals. The latter is a powder that can 
be given in doses of forty-five to sixty grains (3 to 4 gm.) a day in 
capsule or powder, best during meals, without producing any gas- 
tric or intestinal irritation. A very convenient method of adminis- 
tering creosotal is to give it in gelatin capsules, each containing 
twenty to thirty drops, four or five of these capsules being admin- 
istered a day. Some patients prefer to have the remedy admin- 
istered in one dose a day per rectum, especially if they are taking 
other medicine by mouth. Here a good plan is to mix 10 c.c. of 
creosotal with yolk of egg, to stir this mixture into 300 c.c. of warm 
milk, to add a few drops of tincture of opium and to inject this 
quantity into the rectum through a high rectal tube. 

Guaiacol is a useful derivative of creosote that is very popular. Guaiacol 
It may be given as the carbonate, benzoate or salicylate of guaiacol 
in powder form, beginning with five grains (0.3 gm.) three times a 
day and increasing the dose until as much as fifteen to thirty grains 
(1 to 2 gm.) three times a day are being taken. These guaiacol 
preparations are decidedlv more irritating when taken by mouth 
than either creosotal or thiocol. 

Innumerable other remedies have at different times been recom- 
mended as specifics in the treatment of tuberculosis, but none of 



130 



INFECTIOUS DISEASES 



Remedies of 
historic in- 
terest 



Arsenic 



Dose and ad- 
ministration 



Codliver oil 



these has vindicated its claim to usefulness in this disease. Among 
the remedies that possess the greatest historic interest and that 
created much sensation at the time when they were first recom- 
mended are cinnamic acid and its derivatives hetol and sodium 
cinnamate, copper and its salts, and nuclein. I have never been 
assured that these drugs are of any use whatever in the treatment 
of tuberculosis. 

Arsenic is a remedy that possesses no specific power over the 
tuberculous process but may to advantage be used in tuberculosis as 
a general tonic. It may be given in the form of Fowler^s solution 
by mouth, beginning with three to five drops in plenty of water 
three times a day and increasing the dose a drop per dose a day until 
fifteen to twenty drops, three times a day, are being taken. Then 
the amount should be gradually reduced until only three to five 
drops, three times a day, are again being administered; the same 
cycle should be repeated several times. The maximum dose must 
be determined somewhat by the reaction of the patient to the 
remedy. If signs of arsenic intoxication, puffiness about the eyelids, 
epigastric distress, colic, diarrhea, itching about the palms of the 
hands and soles of the feet appear, then the quantity should be 
reduced. Arsenic may also be given by mouth in the form of 
sodium arseniate in the dose of one-one-hundred-and-fiftieth to one- 
fiftieth of a grain, in capsule with sugar of milk, three times a day, 
for indefinite periods of time. Sodium cacodylate, hypo derm ically, 
is one of the best preparations if it is desired to administer large 
doses of arsenic without danger of intoxication. It is particularly 
useful, aside from its action as a general tonic, in aiding absorption 
of pleuritic exudates forming in the course of pulmonary phthisis. 
It is unnecessary to give more than one-fourth of a grain of sodium 
cacodylate in watery solution^ hypodermically, once a day, although 
as much as one grain, several times a day, may be given. The 
patients complain very shortly of a peculiar garlic odor of the 
breath and should be apprised of the probable occurrence of this 
phenomenon when cacodylate injections are made. For contra- 
indications to the use of arsenic and details of administering the 
different preparations see also the Section on Anemia. 

In addition to these remedies various medicinal substances are 
given in tuberculosis more as foods and to replace tissue waste than 
as drugs. Among these codliver oil is the most popular. It is ques- 
tionable whether the iodine it contains, or the alkaloids it is said to 
incorporate, in any way determine its good effects in tuberculosis. 
It is more probable that the fat acts beneficially as a food. Codliver 
oil, moreover, is a very convenient vehicle for the administration of 
a number of remedies (see above) and as the laity have been edu- 
cated to have much faith in codliver oil, its administration generally 



INFECTIOUS DISEASES 131 

exercises a beneficial psychic effect that is by no means a negligible 
quantity in the treatment of tuberculosis. 

The administration of different salts is always indicated in Salts 
tuberculosis, for in this disease the urinary and fecal excretion of 
mineral constituents, especially of the calcium salts, chlorides and 
phosphates,* is exceedingly large. This loss should be replaced Calcium 
artificially, hence tuberculous patients should receive abundant Phosphates 
table salt with their food and should receive phosphates and calcium 
salts medicinally. The latter can conveniently be administered in 
the form of calcium hypophosphite or as syrup of hypophosphites 
containing hypophosphite of calcium, potassium, sodium, free hypo- 
phosphoric acid, spirits of lemon and sugar, in the dose of one to Hypophos- 
two drachms (4 to 8 cc). 

Symptomatic Treatment of Special Symptoms. Provided the Fever 
fever in tuberculosis does not yield to rest, proper feeding, plenty of 
fresh air and the use of creosote preparations, or if the patient 
reacts to even slight elevations of the temperature by especially dis- 
agreeable subjective sensations, such as profuse sweating, great 
prostration, chills, headache, nausea ; or if, finally, the fever remains 
persistently high so as to render it difficult to maintain the patient's 
general nutrition, because the consumption of his own tissues is so 
active, then the symptom, fever, must be specially treated. 

A very simple and generally efficient means of combating slight Alcohol 
rises of temperature is the administration of alcohol, preferably in 
the form of hot toddy, whenever the premonitory signs (chilliness, 
hot flushes, etc., of a febrile attack occur), also in the form of light 
Burgundy or Moselle wine as a table beverage. Early cases of 
tuberculosis, in my experience, are not so apt to develop so much 
fever, and especially such high degrees of temperature, if they take 
some alcohol as when they do not. 

Sometimes it becomes necessary to combat the fever by the use Antipyretics 
of certain members of the antipyretic group, namely, acetanilid, 
phenacetin, antipyrin or lactophenine. Acetanilid, phenacetin and 
antipyrin while effective in reducing the temperature are very liable 
to produce disagreeable sweating. Lactophenine does not seem to 
possess this property, hence it should be the remedy of choice (6ee 
index). Lactophenine and the other remedies enumerated above 
are best given in three to five grain doses about three or four hours 
before the rise of temperature is expected, i. e., as a prophylactic. 
This method of administering antipyretics is much more elegant 
and more efficacious, and moreover requires much smaller doses, 
than if the drugs are given at the height of the fever. 



*See Croftan: The Urinary Calcium Excretion in Tuberculosis, 
Journal of Tuberculosis, 1901. 



132 



INFECTIOUS DISEASES 



Pyramidon is especially useful as an antipyretic. At the same 
time pyramidon or its camphoric acid compound has a tendency to 
reduce the severity and the frequency of night sweats. Some 
patients display an idiosyncrasy against the drug and respond to 
the administration of even small doses with nausea and vomiting. 
In such cases the remedy should not be administered at all and it is 
always well to make a preliminary attempt with small doses. If no 
idiosyncrasy is present the drug is one of great usefulness. 
Hydrotherapy Hydrotherapy is not so useful nor so safe in the reduction of 

tuberculous fever as in the reduction of fevers due to other infec- 
tions. Only very mild hydrotherapeutic measures should be em- 
ployed in any case. Best of all is sponging the different extremities, 
the abdomen, chest and back, singly, with water of room tempera- 
ture, either exposing each part of the body for a short time and 
immediately drying and covering it, or sponging underneath the 
covers. Often it is best to merely rub the hands and feet, legs, arms 
and trunk with the hand that is repeatedly dipped in cold water, 
taking each part of the body singly, rubbing dry promptly and 
following the wet rub by an alcohol rub and friction. Or a towel 
may be wrung out of cool water and placed on one extremity and 
the limb or arm rubbed or slapped through the wet towel. This 
practice is kept up for a minute or two ? the wet towel removed, the 
limb quickly dried, rubbed with alcohol and dried again. Bath 
treatments or more active hydrotherapeutic means are generally 
objectionable in tuberculosis and should be avoided. Cleansing 
baths, so necessary in cases suffering from profuse night sweats, are 
always best given in bed with the patient lying down. Here luke- 
warm water should be used and the bath followed by a brisk alcohol 
rub and massage. 

The night sweats of tuberculosis often call for special treatment. 
Here the old fashioned remedy of washing the surfaces of the body 
with alcohol and water, or vinegar and water, or with a one to 
thirty solution of alum, or a one to two hundred solution of sul- 
phuric acid, are all useful. 

Of recent years formaldehye, in 40 per cent, solution, mixed 
with equal parts of alcohol, has been extensively employed. This 
preparation is remarkably efficacious in stopping the sweating in 
any part of the body and its effect usually lasts for several nights. 
Unfortunately the pungent and irritating odors of formaldehyde 
are disagreeable and may become dangerous to the patient, hence in 
making these applications the windows should be wide open and the 
patient should breathe during the application through a cloth or a 
sponge saturated with turpentine. 

A useful dusting powder to control the night sweats of phythisis 
Tannoform is'tannoform. This should be powdered over the whole body every 



Night sweats 

Alcohol, alum, 
vinegar, sul- 
phuric acid 
washes 



Formaldehyde 



INFECTIOUS DISEASES 133 

night. Salicylic acid and talcum powder mixed in the proportion Salicylic acid 
of one to one hundred also form a useful dusting powder. When 
this preparation is applied the patient should cover his mouth, as 
the salicylic acid is exceedingly irritating to the throat and may 
produce violent coughing. 

For internal use alcohol in the form of brandy or whisky in Alcohol 
milk or water, given in the evening, is occasionally valuable in stop- 
ping profuse perspiration during the night. Atropine in large Atropin 
doses, that is, in one dose of one-fiftieth of a grain (0.0012 gm.), 
hypodermically, or in two or three one-one-hundred-and- twentieth 
grain (0.0005 gm.) doses at one hour intervals, by mouth, before 
going to sleep is very useful. Some patients, however, cannot tol- 
erate atropine without serious discomfort and complain of the dry- 
ness of the mouth and throat following its administration. In such 
cases agaricin in one-twelfth to one grain (0.006 to 0.065 gm.) Agaricin 
doses in pill form is an exceedingly useful remedy, or camphoric 
acid in fifteen to thirty grain (1 to 2 gm.) doses may be given in a Camphoric acid 
powder or a capsule before the patient goes to sleep. 

The cough in pulmonary tuberculosis frequently calls for special Cough 
treatment. If it is due to local causes in the pharynx, the larynx Local treat- 
or trachea, then appropriate topical treatment, i. e., cauterization 
of ulcers or the application of lactic acid or insufflations of iodo- 
form should be employed. The topical treatment of tuberculous 
lesions of the upper air passages should be left to the skilled spe- 
cialist and the technique of this therapy need not, therefore, be 
described in this book. The internist, however, should always care- 
fully examine the upper air passages for ulcers or erosion, as other- 
wise cough medicines, opiates, etc., that may harm the patient, up- 
set his digestion and derange his nerves may be given in vain when 
simple treatment of the local condition would promptly lead to the 
goal. 

Occasionally coughing can be symptomatically relieved by in- Inhalations 
halations of steam through a steam inhaler, as described in the 
Section on Bronchitis. Here sodium chloride or sodium carbonate 
added to the water exercises a very beneficial effect. Or the patient 
may inhale the steam from a bowl of hot water through a paper 
cornucopia, or simply by covering his head and the dish with a 
towel, the water being medicated with a teaspoonful of tincture of Demulcent 
benzoin, or twenty drops of opium tincture with five drops of bella- drinks 
donna tincture to the quart. Demulcent beverages and lozenges 
also frequently give relief, especially if the cough is due to local 
irritation in the upper air passages. A very useful demulcent 
beverage is the following : 



134 



INFECTIOUS DISEASES 



B 



Lozenges 



Education 



Narcotics 



Opium and its 
derivatives 



Expectorants 

Oleoresins 
Balsams 



Position of pa- 
tients with 
cavities 



Digestive dis- 
orders 



Sweet almond oil, 
Mucilage, 
Simple syrup, 
Water, 



10 

10 

10 

200 



Lozenges medicated with eucalyptus, guaiacol, menthol, chloride 
of ammonia, red gum are all useful. 

If these simple remedies fail to relieve the cough, then medi- 
cines must be given internally. In the absence of much secretion, 
i. e., when the cough is irritative in character but non-productive, 
then the education of the patient is frequently an important ele- 
ment in the treatment. Sufferers from any bronchial or tracheal 
trouble are apt to cough much more frequently and more violently 
than is necessary. If they are told to suppress or control the cough, 
when they feel a little tickling in the throat or in the chest, very 
much will be accomplished. Tuberculous cases especially should be 
educated to cough as gently as possible, as there is always danger 
of hemoptysis and spreading of the tuberculous process into remote 
regions of the lung by too violent coughing efforts. In the irrita- 
tive form of cough without much expectoration that cannot be con- 
trolled by the will, narcotics must generally be used, especially if 
the patient cannot sleep on account of the coughing, or if the 
coughing interferes with his eating, destroys his appetite or causes 
vomiting. Here the whole array of opiates, opium, heroin, codeine, 
morphine, dionin, may be employed, as described in full under 
Bronchitis. 

If, on the other hand, the secretion is very abundant, or if there 
are cavities filled with secretion, then opiates should be given very 
sparingly. Here the various expectorants that have been fully de- 
scribed in the Section on Bronchitis should be employed. If the 
secretion is very purulent, then the balsams and oleoresins should 
be used as in any other form of putrid bronchitis. 

Patients with large cavities who suffer particularly from severe 
coughing paroxysms at night should be instructed to attempt evac- 
uation of the cavity by lying on the opposite side to it for a time 
before going to sleep. If this is done evacuation of the cavity is 
promoted and there is less tendency to a paroxysm of cough for 
some hours to come, i. e. ? until the cavity fills up again and its con- 
tents come in contact with healthy bronchial mucosa near the orifice 
of the cavity. The treatment of tuberculous cavities does not other- 
wise differ from that of bronchiectasis as fully described under that 
head. 

The digestive disorders occurring in the course of tuberculosis 
are of great importance and should be carefully considered in the 
treatment because so much depends on the proper feeding of tuber- 



INFECTIOUS DISEASES 135 

culoiis subjects. If there are marked gastric disorders, then a care- 
ful study of the gastric function should be made and the diet and 
medication arranged accordingly. In tuberculosis any variety of 
gastric disorder may occur from simple nervous dyspepsia to dif- Gastric dis- 
ferent combinations of motor, sensory and secretory perversions, 
acute and chronic catarrhs, ulcerative processes with stenosis and 
dilatation or atony of the gastric walls and amyloid degeneration Intestinal dis- 
of the gastric and intestinal mucosa. It will be seen, therefore, that or ers 
the treatment of the stomach will have to vary greatly in each case 
according to the exact character of the trouble that is found. 

Anorexia is a symptom that requires special discussion. It may Anorexia 
occur in any of the above gastric disorders complicating tubercu- 
losis, or it may occur without any marked stomach trouble. It is 
always a difficult condition to deal with. 

A tuberculous subject suffering from lack of appetite or positive Selection of 
aversion to food should be allowed the widest choice in the selection diet 
of his diet, provided there are no distinct contra-indications, as 
revealed by the state of the gastric function to the use of certain 
articles of food that he may crave. Many cases of anorexia are pro- 
duced by one-sided and forced feeding, so that here it is particu- 
larly important that the physician should not be a dogmatic doc- 
trinaire. There are some cases in which the patient declares an 
aversion towards food of any kind and manifests an absolute unwil- 
lingness to eat. In such instances it may become necessary to insist 
upon forced feeding, the patient taking his food as he takes his Forced feeding 
medicine and, here, the diet may have to be one-sided, but it should, 
above all things, be of the most nutritious kind. In extreme types 
of anorexia, especially in hysterial subjects, it may become neces- 
sary to administer food by the stomach tube, the nasal catheter, or stomach tube 
even by rectal injection (see index), in order to prevent the patient Rectal feeding 
from literally starving to death. Most of these cases soon elect to 
sat properly rather than be subjected several times a day to the or- 
deal of artificial feeding. 

In ordering an exclusive milk diet it is best to give a mixture of Exclusive 
milk and cream, about two-thirds milk and one-third cream with milk-cream 
a teaspoonful of brandy and a tablespoonful of lime water to each 
tumbler full. This mixture may be given every two or three hours 
during the day. If administered cold the patients rarely object to 
this one-sided feeding. If raw meat is given, and this food seems Raw beef 
to be of particular value in tuberculosis, then at least 200 grammes 
of meat should be used in the twenty-four hours. The best method 
of preparing it is to scrape the raw beef, to grind the pulp in a 
mortar and then to press it through a sieve. It may be rendered 
palatable by mixing with mashed potatoes and seasoning with 



136 



INFECTIOUS DISEASES 



Causal treat- 
ment of an- 
orexia 
Fever 



Coughing 



Pain on swal- 
lowing 



Stomachics 
and bitter 
tonics 



Constipation 



Diarrhea 



Insomnia 



plenty of salt, or it may be mixed with one or two eggs and flavored 
with pepper and salt or with lemon juice. 

Every case of anorexia should be submitted to careful study and 
the cause of the aversion to food discovered if possible. Sometimes 
the high fever itself disturbs the appetite of the patient, then every 
effort should be made by the judicious employment of antipyretics 
and of hydrotherapeutic means (see above) to keep the fever down. 
Often the administration of five grains of lactophenine, two or 
three hours before each meal time, will accomplish the desired re- 
sult. In other cases the coughing interferes so much with eating 
that the patients prefer not to eat at all. Here a little codeine or 
dionin, or in extreme cases a hypodermic of one-fourth grain of 
morphine with one-two-hundredth of atropine, may be given about 
an hour before each meal. In still other cases there is so much 
pain on swallowing that the patients refuse to eat for this reason. 
Cocaine employed locally on cotton pledgets, as a spray, or by in- 
sufflation occasionally relieves the pain and enables the patient to 
swallow. In less severe cases cold must be applied to the throat, 
both externally by the application of ice cloths and internally by 
swallowing ice pills. In all these cases a liquid diet consisting of 
broths, predigested food and the milk-cream food described above, 
may be given. Very hot, highly seasoned liquids should, of course, 
be avoided. Cases suffering from tuberculous ulceration of the 
larynx and the epiglottis can often swallow better if lying on their 
stomach and sucking the liquid food through a straw. 

Stomachics and bitter tonics are of very little value in improv- 
ing the anorexia in tuberculosis. Five to ten drops of the tincture 
of nux vomica^ or a tea spoonful of the compound tincture of carda- 
moms or of gentian after meals can, however, do no harm. 

The treatment of the constipation that not infrequently de- 
velops in tuberculosis, especially if one-sided albuminous feeding is 
adopted and much opiate is given, will be found described else- 
where. Tuberculosis cases eating an abundant amount of fat food, 
however, rarely suffer from very obstinate constipation. 

Diarrhea, intestinal fermentation and meteorism must be 
treated as described in the appropriate chapters. The diarrhea 
of tuberculosis is a particularly obstinate symptom and dangerous, 
especially if it is due to ulcerative processes in the bowel or to 
amyloid degeneration of the intestinal mucosa. 

Insomnia, in tuberculosis, is, as a rule, due to the cough, the 
fever or to the pains, pleuritic or otherwise^ about the chest, or to 
digestive disorders, flatulency, meteorism, etc. With the removal 
of these causes insomnia usually improves. If it does not, then the 
sleeplessness must be treated symptomatically with the aid of reme- 
dies described. 



INFECTIOUS DISEASES 137 

The treatment of the hemoptysis of pulmonary tuberculosis has 
been discussed in full in the Section on Hemoptysis. 



SYPHILIS. 

Dr. F. Kreissl, Chicago. 

The treatment of syphilis is both a local and a constitutional 
one. 

(1) With local treatment we attempt to destroy, or at least Local treat- 
weaken, the specific virus wherever its initial presence is evidenced ment 
by pathological lesions. This may be accomplished by cauteriza- 
tion or by excision of the venereal sore. 

According to Fournier excision gives an average of one success Excision of 
in five cases, the success depending upon the length of time between ulcer 
the appearance of the chancre and its surgical removal. Even if 
failure as an abortive procedure occurs, the excision of the chancre 
certainly renders the subsequent course of the disease milder. 

The cauterization of the venereal ulcer is less effectual as an Cauterization 
abortive means. In fact, I do not believe that such is possible, but °* ulcer 
it unquestionably lessens the severity of the subsequent symptoms. 
Neither procedure is indicated when the adjoining lymphatics are 
already involved. 

The venereal ulcer should be treated on general surgical prin- Venereal 
ciples like any other wound. We employ mild antiseptic solutions, 
like two per cent, carbolic acid, or 1 in 3,000 bichloride of mercury 
for cleansing, followed by a thin layer of dusting powder on the 
dried surface. Most effective, but obnoxious on account of its 
odor, is iodoform used pure or with equal parts of boric acid. In- 
stead of this dermatol, iodol, or europhen may be employed. Gauze 
compresses saturated with any of the above solutions may be applied 
several times a day to chancres with sluggish granulations show- 
ing little tendency to heal. Gangrenous or phagedenic chancres Gangrenous 
require cauterizing with the Paquelin, followed by the application chancre 
of the nitrate of silver pencil, or a ten per cent, zinc chloride solu- 
tion, or nitric acid. Sometimes cauterization will have to be pre- 
ceded by a thorough curettage of the ulcer, both procedures re- 
quiring a general anesthetic. As soon as the ulcer has a healthy 
appearance and one does not wish to commence with the constitu- 
tional treatment, it should be covered with Unna's mercury plaster 
mull, to be changed once or twice a day, depending on the amount of 
wound secretion. This plaster mull is applied even after the sore 
has healed, as long as the induration is noticeable. If phymosis has Phymosis 
been caused by chancre, and if the latter is not accessible to local 



138 



INFECTIOUS DISEASES 



Vaginal 
chancre 



Venereal papil- 
loma 



Paquelin 
cautery 



Suppurations 

Suppurating 

glands 



treatment, we expose the ulcer by circumcision or by a dorsal divi- 
sion of the prepuce. 

Chancres in the vagina and on the cervix are exposed by a 
speculum and treated in the same manner as elsewhere, but the 
mercury is applied as ointment on a gauze tampon. The latter 
has to be omitted during pregnancy and in its stead vaginal 
balls of equal parts of cocoa butter and mercury ointment are 
inserted. Initial lesions in the mouth and on the tonsils require 
daily applications of a ten per cent, solution of bichloride of 
mercury in alcohol or ether. 



Venereal papillomata yield to the daily application of re- 



sorcm. 



*} 



Resorcin 9.0 

Sacchar. 1.0 

Sig. Dusting powder. 



Or 



JJ 



Resorcin 5.0 

Aqua destil. 100.0 

Sig. Apply on gauze sponge. 



Or 



V 



Acid lactic 

Ether sulph. aa 10.00 

Hydrarg. bichlor. cor. 0.10 

Sig. Apply with a brush once a day. 

Very effective because one application usually suffices is: 

Plumb, causticum 

Solut. kalii caustic (30 per cent.) aa 7.50 

Lithargyri 0.25 

Sig. Apply with the point of a wooden stick. 

This mixture is applied to the whole growth and the healthy 
skin protected during the application. Papillomata resisting 
this treatment are curetted and cauterize! with Paquelin. The 
condylomata around the anus usually disappear under calomel 
dusting powder and an isolating gauze pad. 

Indurated lymph glands are covered with mercury plaster 
mull. 

Suppurating glands have to be opened and treated in the 
following manner: After shaving and cleansing the region in 



INFECTIOUS DISEASES 139 

the customary way and anesthetizing with ethyl-chlorid, an in- 
cision is made in the long axis of the bubo and carried down to 
the pus cavity; the latter is not only exposed, but its contents 
are squeezed out with the fingers by rather hard pressure all 
over the region. This is kept up for a minute or so until the 
fluid becomes free from pus and appears sanguinolent. The 
abscess cavity should not be irrigated, only the edge of the 
wound cleansed with boiling hot water. Now the wound is 
closed by an interrupted horsehair suture. No drainage is nec- 
essary. The region is cleansed with hot sponges once more and 
a gauze collodion dressing applied. Over this comes a com- 
pressing pad and bandage to be maintained for several days. 
The sutures are removed after ten days, at which time, if at all, 
healing by primary union has occurred. 

Onychia and paronychia require a daily local bath in bi- Onychia 
chloride of mercury solution in the strength of 1 in 2000, followed Paron ychia 
by a dusting with 

Calomel 2.0 

Talcum venet. 20.0 

Sig. Dusting powder. 

Gummata which are not yet liquefied or not exulcerated are Gummata 
often absorbed by tincture of iodine or mercury plaster mull, or a 
ten per cent, calomel traumaticin applied daily. 



Calomel 


5.00 


Traumaticin 


20.0 


Sig. Shake well, apply with brush. 





An exulcerated gumma is treated like a phagedenic ulcer; mu- 
cous patches in the mouth like ulceration therein. 

The constitutional treatment should be commenced as soon as Constitutional 
the syphilitic character of the ulcer is with certainty established treatment 
and the healing process retarded and in all secondary and tertiary 
manifestations of the disease. The sovereign remedy is mercury. 
It is administered: 1. By mouth. 2. By inunction. 3. By in- 
jection. 

Preceding the treatment attention should be paid to the condi- 
tion of the gastro-intestinal tract, the diet regulated, the urine Mercury by the 
examined and the mouth and teeth put in the best possible condi- moutn 
tion. 



140 



INFECTIOUS DISEASES 



Mercury 
tannate 



Mercury 
protoiodide 



Cypridol 



By mouth, mercury is given in pills or capsules, but we must re- 
member the caustic action of the drug on the intestinal tract. Hy- 
drargyrum oxydulatum tannicum is very effective. 

9 

Hydrargyrum oxyd. tannic, 2.50 

Opii p., 0.25 

Sacch. lact. 3.50 

Lanolin 1.25 
M. f. pill— No. 50 
Sig. Four to six pills a day. 

Opium is added when the bowels are very loose. Hydrargyrum 
oxydulatum tannicum is incompatible with carbonates and iodin 
preparations. 

Equally reliable as the above is 



S 



1.50 
0.50 
1.50 

4.50 



Mercury 
unction 



by in- 



Hydrarg. protoiodid. 

Decoct, opii aq., 

Lanolin 

Sacch. lact. 

M. f. pill— No. 50. 

Sig. Four to five pills a day. 

The prescription should call for a small number of pills, in or- 
der that they may be fresh. Those which are kept in stock are 
sometimes very old and get so hard that the gastro-intestinal juices 
are not able to dissolve them; many disappointing results are due 
to this fact. 

Mercury, given by mouth, should be taken immediately after a 
meal. In case of diarrhea its use must be discontinued and opium 
given. If the intestinal irritation recurs after the drug is resumed, 
this mode of treatment must be abandoned and inunction or injec- 
tions resorted to. More recently cypridol, a one per cent, solution 
of biniodide of mercury in oil, has been used. It is given syste- 
matically for three weeks in the first three months in doses of two 
capsules, three or four times a day after meals. For the following 
three months the same amount is given every alternate fortnight 
and after that eight days of each succeeding month for three consecu- 
tive years. The claim is made that it is not as irritating to the gastro- 
intestinal tract as the other preparations of mercury, which limits 
their value on account of the small amount of the drug that can 
be administered by mouth. 

For inunctions unguentum hydrargyri is used, mixed with equal 
parts of unguentum petrolatum. It is dispensed in gelatin cap- 
sules or in paraffin paper, each containing two to three grammes of 
the ointment for an adult and one-half to one gramme for a child. 



INFECTIOUS DISEASES 141 

Unguenti hydrargyri 

Unguenti petrolati aa 1.50 

(Caps, gelatin) paraffin paper No. XII. 

Sig. Use as directed. 

Wherever possible easily accessible hairless portions of the skin Technique 
are selected, and each inunction applied to new parts following a 
set cycle as, for instance, 

First night — arms and forearms. 

Second night — both sides of chest. 

Third night — the loins. 

Fourth night — the abdomen. 

Fifth night — inner surface of thighs. 

Sixth night — no inunction, warm bath. 

Seventh night — inunction as on first night, etc., etc. 

In this way unnecessary cutaneous irritation is usually avoided. 
(Eczema mercuriale — Folliculitis — Toxic Erythema.) The inunc- 
tion should be made by the patient himself, but if made by any- 
one else rubber gloves should be worn. Each rubbing requires about 
twenty minutes, and it is a good plan to rub in small portions — 
about the size of a bean — of the ointment, this procedure to be 
repeated when the skin becomes dry. 

The disadvantages of this mode of treatment are its uncleanli- iDiisadvantages 
ness; the irritating effect on the skin; the time consumed by each inunctions 
application ; and the impossibility of an exact dosage. Most of the 
mercury contained in the ointment evaporates when brought in 
contact with the living body, the greater part of the vapors enter- 
ing the system through the respiratory organs, the smaller part 
through the skin. This explains why patients treated under oth- 
erwise identical conditions sometimes are easily salivated and at 
other times do not seem to respond to the treatment at all. These 
different observations largely depend on the temperature surround- 
ing the body after the inunction. Instinctively older syphilologists 
ordered the inunctions to be made in superheated rooms and had 
the patients wrapped in flannel blankets for hours afterwards. 

Instead of the mercurial ointment, mercury plasters or plaster Mercury plas- 
mull spread over large areas of the body may be used to advantage. ers 
especially in children. It is renewed once a week. 

Emplastr. hydrarg. oleinicum 

Emplastr. plumbi olein. aa 140.0 

Hydrargy depur. 

for adults 60.0 

for children 30.0 

Sig. Plaster. 



142 



INFECTIOUS DISEASES 



Mercury baths 



Injection 
ment 



treat- 



Technique 



Another way of administering mercury externally is by bichlor- 
ide of mercury baths, but, in order to be really effective, i. e., to 
penetrate through the skin, they must be given in connection with 
electric kataphoresis, which is accomplished by the electric two-cell 
bath. 

The quantity required for a bath varies from ten to fifteen 
grammes of bichloride of mercury. It is useful in the treatment of 
very young children, and in moist papular, pustular, and ulcer- 
ating syphilitic lesions on the skin. 

For the intramuscular application of mercury soluble and in- 
soluble preparations are employed. They are injected hypodermic- 
ally or intramuscularly. Best known and most generally used, 
among the soluble preparations, is the bichloride of mercury. It 
is prescribed in one per cent, to five per cent, solutions to which is 
added sodium chloride, which prevents the precipitation of albumin- 
ates of mercury. 



b 



Hydrarg. bichlor, corros. 

Natr. chlor. 

Aqua destill. 

Sig. Bichloride solution. 



1.0-5.0 
1.0-5.0 
100.0 



Usually 1 cc, equal to 0.01 of bichloride of mercury, is in- 
jected in i\ie gluteal region daily, or every other day, as the case 
may require. It is well to follow a certain routine in injecting. 
The injections should be given alternately in the left and right but- 
tock, in and outside of a vertical line crossing its highest elevation, 
so that the solution is deposited in a new place each time. It 
should be injected slowly in order to avoid painful bruising and 
unnecessary destruction of tissue; a slight massage following the 
withdrawal of the needle will spread the fluid over a larger area. 
The syringe may be made entirely of glass or of glass with hard 
rubber trimmings, the needle of platinum-iridiurn — l 1 /^ to 1% 
inches long and narrow gauged. When using shorter needles the 
fluid is placed too close to the skin, causing inflammation, eventual- 
ly even necrosis. What little pain is experienced ceases soon or is 
shortly checked by the application of heat. The platinum-iridiurn 
needle is preferable to a steel needle because the latter easily be- 
comes corroded and punctured along its walls, allowing the solu- 
tion to escape through these little holes into tissues close to the 
skin, producing the above inflammations. It is hardly necessary to 
say that the same antiseptic precautions as in ordinary hypoder- 
mic injections should be rigidly observed, or to mention the rare 
possibility of an embolus, due to the puncturing of one of the 
large gluteal veins and injection into it. 



INFECTIOUS DISEASES 143 

Cypridol may also be injected hypodermically like bichloride of 
mercury in the dosis of 0.5 cc, equal to one one-hundredth grain 
of the bichloride. The needle used must be of larger size on ac- 
count of the oil passing through it. Otherwise the same rules as in 
bichloride injections apply to its application. 

Of the insoluble mercury preparations Lang's "gray oil" has Lang's "gray 
stood the test of many thousand cases within the last twenty years. ol1 
It is a compound of fat, oil and metallic mercury, dispensed as a 
fifty per cent, and a thirty per cent, liquid. The former consisting 
of two parts of mercury and one part each of lanolin and vaselin oil. 

Unguent cinereum lanolinat. forte 9.0 

Olei vaselini 3.0 

Sig. Oleum cinereum 50 per cent. 

The fluid is slightly warmed and well shaken before being used. 
The dose for one injection is 0.05 cc, equal to 0.04 of metallic mer- 
cury, and is administered in intervals of three days until a decided 
improvement in the symptoms becomes apparent, when but one in- 
jection a week is given and two more injections in an interval of 
two weeks after all symptoms have subsided. More than twelve 
injections are rarely required to accomplish this end. 

The oil is deposited in the back about two inches from the dor- Technique 
sal spine. The needle is inserted almost parallel to and under- 
neath the cutis. If this is done the injection is almost painless 
and not followed by induration and inflammation. This is due to 
the lack of corrosive properties of the remedy and the very small 
quantity incorporated which precludes bruising or destruction of 
tissue. Each following injection should be placed about two inches 
from the preceding one. If it is desired to inject more than 0.05 
cc. this should be done in two equal parts of 0.05 cc. and in two 
different places. The advantages of the gray oil are, as said be- 
fore, the small volume required for one application, the absence 
of reactive inflammation and the greater stability of the prepara- 
tion which establishes a reserve in the tissues to draw upon much 
longer than from soluble mercury solutions. But therein lies also 
the danger of an oversupply in the hands of those not familiar 
with the drug, the disease and the symptoms. 

Eeviewing the various methods of administering mercury, we Comparison of 
can see the superiority of subcutaneous injections. They permit usmg mercury 
an exact dosage, guarding in this way against either mercurial in- 
toxication by an overdose, or insufficient action by loss of part of 
the drug on its route to the circulation. No inconvenience in their 
application is experienced, no uncleanliness likely to call the at- 



144 INFECTIOUS DISEASES 

tention of others to the ailment connected with it, and gastroin- 
testinal irritation and skin lesions are practically unknown. 

Tonics Simultaneously with the administration of mercury a tonic 

must be given. I have found peptomanganate of iron and iron- 
tropon most valuable. 

Mercurialism Irrespective of the way mercury is incorporated, symptoms of 

mercurialism are occasionally observed; sometimes due to an over- 
dose and at others to an individual idiosyncrasy. The manifesta- 
tions observed are stomatitis, gastro-intestinal irritation, toxic 
erythema, anemia, neuritis. As soon as these symptoms occur, 
the administration of mercury must be discontinued. Most of 
the trouble soon passes off and the treatment may be resumed. In 
the cases of idiosyncrasy other remedies will have to be employed. 

Iodine prepara- Iodine is next in value to mercury and most used in combating 

tions syphilis, especially potassium iodide, sodium iodide and rubidium- 

iodide. The latter is comparatively free from the toxic qualities of 
the other two preparations. The dose varies from 1.0 to 10.0 gms. 
and more pro die. It is given by mouth in liquid or pills, excepting 
in intolerance of the stomach, when it is used in aqueous solution 
by rectum. 

Potass, iodid, 



Or 



Or 



Or 



Or 



Sodium iodid, 



Eubid. iodid, 5.0-10.0 

Aqua distill., 200.0 

Sig. One to three tablespoonfuls in water, es- 
sence of pepsin, or milk, three times daily. 



3 

Potass, iodid, 10.0 



Sodium iod. 

Sacchar. lact., 5.0 

M. Ft. Pill No. 50. 

Sig. Two to ten pills a day. 

lodism The most common symptoms of iodine intoxication ( iodism ) are 

severe headache, coryza, edema around the eyes, cough, acne and 
iodine exanthema. Should any of these symptoms appear the iodine 



INFECTIOUS DISEASES 145 

medication must be discontinued. The addition of a grain of bel- 
ladonna extract to fifty pills frequently prevents iodism. 

Potassium iodide is incompatible with calomel, forming a caus- Incompatibles 
tic compound and the two should not be prescribed together. 

All iodide preparations are very effectual in the late forms of 
syphilis — serpiginous syphilide of the skin, gummata of the skin, 
fascia, muscles and bone syphilis, ulcerations of the pharynx and 
larynx, syphilis of internal organs and the central nervous system. 
They have to be used in malignant syphilis, instead of mercury, 
at least for a while preceding the administration of the latter 
drug and in all cases of idiosyncrasy for mercury. It is very ef- 
fective with or without antipyrin for severe headache, pain in 
bones and joints preceding or accompanying the eruptive stage. 

Potassium iodid, 4.0-8.0 

Aqua destilL, 200.0 

Antipyrin, 2.0-3.0 

Sig. A tablespoonful in water, twice or three 
times a day. 

It is the remedy of choice in syphilis in tuberculous, scrofulous, Mixed treat- 
highly emaciated patients. In malignant syphilis, iodin prepara- men 
tions instead of mercury are used until the general condition of 
the patient permits the employment of the latter drug. The in- 
dications for the choice of iodin in these cases are easily recognized 
by the fact that in spite of the mercury the progressive nature of 
the lesions cannot be checked. In some very stubborn cases decided 
improvement will follow the combined administration of iodine and 
mercury after either of them employed separately have failed to 
be effectual. 

How long to continue the treatment of syphilis depends on Duration of 
the views one holds regarding the nature of the trouble. Some rea men 
believe in the temporary treatment, others in the continuous treat- 
ment, and the followers of Fournier in the chronic intermittent or 
interrupted treatment. While the adherents of the first method 
believe in treating only in the presence of visible lesions, the advo- 
cates of the second method administer mercury, or mercury alter- 
nating with iodin and other drugs, more or less continuously for 
a number of years, irrespective of the presence or absence of 
luetic manifestations. The temporary treatment evidently is in- 
adequate, while under the continuous method a tolerance for the 
specific drugs is established which weakens their therapeutic effect. 

The best results are observed with the third method. The treat- 
ment should extend over a term of not less than three years, and 
in the absence of special indications not over five years. If in- 



146 



INFECTIOUS DISEASES 



Hereditary 
syphilis 



jections or inunctions are used, the patient should first receive as 
many as are required to make the symptoms disappear, and then 
half as many more. Then comes an interval of about two months 
which, in the first year, may be utilized to give iodine for four 
weeks. Then again half as many injections or inunctions as were 
given altogether in the first course, and this followed by four weeks 
of iodine medication and four weeks of rest. The same procedure is 
repeated once more. In the second and third year, unless the indi- 
cations require a change from the routine^ this course of treatment 
may be given twice each year ; and in the fourth and fifth year one 
course only. 

Hereditary syphilis has to be treated upon the same principles 
as the acquired form. As a result of the preventative mercurial 
treatment of a luetic mother apparently healthy children are fre- 
quently born. The same procedure ought to be tried where the 
mother appears healthy but the father is luetic. 



'606' 



Mode of 
action 



Technique 



SALVARSAN. 

The recent discovery of salvarsan, commonly called "606," by 
Paul Ehrlich, has caused a wave of excitement in the profession 
which has not yet — a couple of years after its first publication — 
subsided. And yet many of the expectations which were aroused 
by the discovery have not materialized. However, it can be said at 
this moment, that we possess in salvarsan a most powerful aid in 
combating the symptoms of syphilis in its various stages, and that 
among the arsenic preparations it is the most efficient and the least 
toxic one. 

Salvarsan is an arsenic compound, dioxy-diamino-arseno-benzol, 
to which the short name "606" was temporarily given because it 
was the six hundred and sixth compound tried by Ehrlich. It is 
not a germicide, at least it does not kill the spirochete pallida in 
the test tube, but it certainly destroys the same in the body fluids 
and living tissues. The theory may be correct that it generates in 
the body a substance which disintegrates and destroys the spiro- 
cheta very rapidly. Cases in which injections given to syphilitic 
mothers cured their nursing and syphilitic infants, although no 
arsenic was found in the milk of the mothers, may be accepted as 
strong evidence in favor of this theory. 

Salvarsan occurs as a pale yellow powder and is put up in sterile 
sealed glass tubes. Its solutions are not stable and should there- 
fore be freshly prepared shortly before being used. 

The remedy is administered by injection in three different ways: 

1. Intramuscularly. 

2. Subcutaneously. 

3. Intravenously. 



INFECTIOUS DISEASES 147 

For the intramuscular injections a 10 cc. record syringe with Intramuscular 
a needle measuring six centimeters is employed. The acid solutions 
originally employed have been discarded as dangerous, very painful 
and not very efficient. Hardly less painful are the alkaline solu- 
tions, they are also followed by infiltrates. Neutral solutions are 
difficult to prepare and give rise to necrotic areas. 

These untoward effects and the realization of the impossibility 
of curing syphilis with a single salvarsan injection explain the 
change in the mode of its administration and the transition to 
intravenous injections. The latter are not followed by a local 
reaction, they are practically painless and can be repeatedly admin- 
istered. They are particularly powerful, if combined with intra- 
muscular injections. 

The technique, while not exactly simple, is by no means very Intravenous 
difficult. Various forms of apparatus are employed, each one re- injec 10n 
quiring the aid of at least one assistant. The apparatus of Wein- 
trand Assmy consists of a standard, measuring about three feet in 
height, bearing supports for two cylinders, each holding 200 cc. 
These cylinders taper to a coupling-piece to which a rubber tube is 
attached. Both tubes are provided with a two-way stopcock, and 
the latter ends in a conical tip, which fits into a venepuncture 
needle. Into one of the cylinders physiologic salt solution at a 
temperature of 40° C. is poured. The other cylinder is filled with 
the salvarsan solution. The latter is prepared by dissolving to a 
perfectly clear solution 0.4 to 0.6 gm. of salvarsan in the necessary 
amount of normal sodium hydrate solution and diluting to 200 cc. 
with sterile normal salt solution. The resulting mixture must be 
perfectly clear and transparent. A rubber bandage is applied to the 
arm above the elbow sufficiently tight to constrict the veins below 
but not so tight as to interfere with the arterial circulation. One 
of the larger veins, preferably at the bend of the elbow, is punctured 
with the needle and the constricting band removed. Immediately a 
small amount of salt solution is allowed to flow into the vein to 
make sure that the point of the needle is in the venous lumen. The 
stopcock is next changed to allow the salvarsan solution to flow in, 
and finally about 10 cc. of the normal salt solution is allowed to 
flow into the needle. 

To prepare the salvarsan solution proceed as follows: 

Into a sterilized 250 cc. volumetric flask pour 60 cc. of the Preparing the 
sterile salt solution. The sealed glass tube containing the salvar- 
san is dipped into a bichloride solution or wiped with alcohol and 
opened with a file which is likewise sterilized before being used. 
The contents of the tube are poured into the flask and vigorously 
shaken for several minutes until a perfectly clear solution results. 
Now the sodium hydrate solution is added, five to ten drops at a 



148 



INFECTIOUS DISEASES 



Author's 
method 



Apparatus 
employed 



time, and the flask shaken. A flocculent precipitate will be thrown 
down which is readily dissolved by the addition of more sodium 
hydrate solution. The latter should now be added a drop at a time 
until a perfectly clear solution is again obtained. Then a suf- 
ficient quantity of the salt solution is added to bring the entire 
quantity up to 200 cc. and the flask set in a vessel filled with warm 
water of blood temperature. 

The author employs a method which is less complicated and also 
prepares the solution in a different way. The results obtained in 
hundreds of his cases are uniformly satisfactory and so far no un- 
toward symptoms or disagreeable accidents have been noticed. It is, 
of course, imperative that the finished' product be sterile, which 
means that all solutions and containers used should be sterile to 
begin with; and the resulting solution must be perfectly clear and 
free from solid particles. A salt solution is made by adding eight 
and one-half grammes of chemically pure sodium chloride to one 
thousand cubic centimeters of distilled water. This should be fil- 
tered and then sterilized. The sodium hydrate solution should also 
be filtered and boiled. The author uses a 4 per cent, solution in- 
stead of the 15 per cent, solution usually employed, as there is less 
liability of having an excess of the alkali, which renders the solu- 
tion cloudy. 

The apparatus which the author employs for the intravenous 
injections consists of a 20 cc. record glass syringe, a glass tube 15 
inches long with a 3-inch right angle bent at one end, two pieces of 
rubber tubing 20 inches long^ a V-shaped glass tube, 2 short pieces 
of rubber tubing, a glass connecting point and a venepuncture 
needle. The whole apparatus having been sterilized the long glass 
tube is inserted into the flask, one of the long rubber tubes attached 
to the bent end of the glass tube, the other one to part A of the V- 
shaped tube. The second long rubber tube is attached to part B 
of the latter, and to a small glass connecting point. One of the short 
rubber tubes is connected with point C of the V-shaped glass tube, 
the other short rubber tube with the butt end of the injection 
needle. The glass syringe is then connected with the rubber tubing 
leading to point C, a clamp placed to the long rubber tubing lead- 
ing to point B, and the piston withdrawn. There will be some 
fluid and a good deal of air in the syringe. The latter is discon- 
nected from the tubing, the air expelled in the customary manner, 
and the syringe reattached and filled. The tubing leading to A is 
now clamped, the clamp at tubing B opened and the air from the 
latter expelled by forcing the solution through. The vein is then 
made prominent in the previously mentioned manner, the needle 
inserted into the vein and the constricting band removed as soon 
as blood flows from its butt end. The glass connecting point is now 



INFECTIOUS DISEASES 149 

inserted into this end and the injection commenced. By alternately 
clamping and releasing tubes A and B, the syringe is filled and 
emptied. It takes from 5 to 10 minutes, depending on the size of 
the vein, to complete the procedure. If the technique has been 
perfect no local reaction will be observed. 

The intravenous injections are well borne by patients whose The reaction 
heart, lungs and kidneys are intact. Soon after the injection a 
general reaction appears, consisting of chills, fever, nausea, vomit 
ing, headache, pain in the back and extremities and sometimes 
diarrhea. Therefore the patient should go to bed shortly after the 
injection and remain there until normal conditions are restored. 
This is usually the case within twelve to forty-eight hours. In some 
cases the author has observed a delay in the reaction, the latter ap- 
pearing after twelve to twenty-four and even forty-eight hours. 
Sometimes all of the symptoms are present, sometimes only one 
or the other. Sometimes the reaction is very severe, at others but 
slight. If the injection be repeated after an interval of several 
weeks the reaction may recur or but a very slight one lasting for 
an hour or less. The reaction is considered as due to the destruc- 
tion of the spirochete and the liberation of the toxins, the severity 
being proportionate to the number of spirochete encountered. Effect of 

The effect of salvarsan upon the manifestations of syphilis can 
not be disputed. Nearly every form of syphilis yields with re- 
markable promptness to this treatment. The most striking results 
are observed in the malignant tertiary forms of syphilis. It is 
also beneficial in hereditary syphilis of infants and young chil- 
dren if given in proportionately smaller doses.* No definite result 
can be expected in metasyphilitic affections. In locomotor ataxia 
all the symptoms which are subject to wide spontaneous fluctuations 
frequently show a decided improvement, sometimes to such a de- 
gree that these symptoms do not recur for quite a long time. Of 
course one can not expect reflexes which have been lost by organic 
tissue changes to reappear. 

Nothing can be stated as to the permanence of the effects of 
salvarsan in the favorable cases, and still less regarding a complete 
cure. While the visible symptoms of syphilis disappear much more 
rapidly than under the mercury treatment the Wasserman reaction 
remains positive just as long or reappears just as soon as it does 
under the latter. 

So that at the present time conservative observers can only say 
that a single injection of salvarsan is equivalent to a course of 
treatment with mercury; that it produces marked symptomatic 
effects in malignant syphilis, not infrequently even saving a life, 



♦In infants and small children Salvarsan is a dangerous remedy, 
the mortality from its administration heing very great. — A. C. C. 



150 INFECTIOUS DISEASES 

where mercury and iodine proved powerless ; that in cases in which 
recurrences appeared in spite of repeated courses of mercury sal- 
varsan produced a symptomatic cure extending over a long period. 
Results Since no positive and permanent cure with salvarsan has yet 

been proven, we must either experimentally administer it at certain 
intervals until the Wasserman reaction has remained negative for 
at least one year after discontinuing the drug, or we must employ 
mercury subsequent to the salvarsan, although less actively and at 
much longer intervals. 



CHAPTER II. 

DISEASES OF THE BLOOD. 

THE ANEMIAS. 

The nomenclature and classification of the anemias is involved Nomenclature 
and confusing. Every anemia is characterized by a reduction of an d definition 
the hemoglobin (oligochromemia). Pernicious anemia is char- 
acterized by the appearance of morphological elements in the blood 
(megalocytes and megaloblasts) that are not normally present; 
in other words, there is always a qualitative perversion of the blood- 
forming function, involving chiefly hemopoiesis in the bone mar- 
row (megaloblastic degeneration and reversion to an embryonic 
type). In simple anemia there is merely under- or over-activity 
of this function without qualitative perversion. 

Until recently the pernicious variety was called primary 
(progressive) anemia, and the simple variety, secondary anemia. 
This nomenclature is incorrect, for pernicious anemia is by no 
means always a disease sui generis, nor "idiopathic," but often 
like simple anemia directly traceable to definite and determinable 
causes; and simple, so-called secondary anemia not infrequently 
develops into pernicious, so-called primary anemia. 

For the sake of clearness, therefore, the anemias in this chap- 
ter will be discussed under the headings of Progressive Pernicious 
Anemia, Simple Anemia and Chlorosis; the latter disorder present- 
ing the blood picture of a simple anemia, but differing from all 
other simple anemias, both in regard to its genesis, its blood path- 
ology and its treatment, and hence calling for special and separate 
discussion. 



PROGRESSIVE PERNICIOUS ANEMIA. 

The causal treatment of pernicious anemia must consider Causal treat- 



many factors. Many cases of progressive pernicious anemia have 
been found to be due to the presence of intestinal parasites, nota- 
bly bothriocephaliLS latus, so that in all cases this intestinal para- 
site should be looked for, and removed, if it is found. Here the 



ment 



Intestinal 
parasites 



152 



DISEASES OF THE BLOOD 



Autotoxemia 
from the 
bowel 



Blood para- 
sites 



Syphilis 



Pregnancy 



Achylia 
gastrica 



Chronic under- 
nutrition 



results are brilliant, for this variety of pernicious anemia is dis- 
tinctly curable by removing the cause. Other parasites of the 
bowel can also be incriminated with producing pernicious anemia, 
and, for this reason, anthelmintics, administered as described under 
Diseases of the Intestines, should as a preliminary step always be 
given a full trial in every case of progressive pernicious anemia that 
comes under observation. There is also some evidence to show that 
other forms of bowel intoxication may occasionally produce per- 
nicious anemia, and for this reason free evacuation of the bowel 
contents should be promoted in all cases by the administration of 
laxatives ; the latter being to advantage combined with some of the 
intestinal antiseptics (see index). 

Again blood parasites, notably the plasmodium of malaria, 
filaria sanguinis and distoma liematobium should be looked for and 
their removal attempted. Here quinine and other drugs as de- 
scribed elsewhere are the best remedies. Syphilis, too, occasionally 
produces pernicious anemia and antiluetic treatment will lead to 
the goal more rapidly than any measures directed towards improv- 
ing the condition of the blood symptomatically, although the prog- 
nosis, in syphilitic anemia of the pernicious type, is not favorable 
even under antisyphilitic medication. The same applies to the 
pernicious anemia occasionally seen in pregnant women. Statistics 
show that even the induction of premature labor and the removal 
of the fetus exercise no beneficial effect on the pernicious anemia 
of pregnancy after it has once become established. 

Disturbances of the gastric function, varying from mild de- 
grees of dyspepsia to complete achylia gastrica, almost invariably 
precede pernicious anemia and accompany it throughout. Whether 
the anemia (remaining undiscovered) is primary, the dyspepsia 
secondary, or vice versa, it is generally difficult to decide, and I am 
strongly inclined to the belief from a study of many case reports 
and from personal observations that gastro-intestinal disorders in 
the overwhelming majority of the cases usher in the disease. One 
could consequently imagine such cases of pernicious anemia to be 
the result either of chronic undernutrition or of a gastro-intestinal 
self-intoxication resulting from perverted digestive secretion, or 
both. 

The fact that not every case of chronic undernutrition or of 
autointoxication develops into pernicious anemia calls for the in- 
clusion of some specific factor or factors of hitherto unknown char- 
acter, possibly of varying origin, of which the bothriocephalus toxe- 
mia, for instance, would be a prototype. 

Since I have been paying attention to the gastric function in 
every case of profound anemia presenting the morphological char- 
acteristics of the pernicious type, I have observed either complete 



diet 



DISEASES OF THE BLOOD 153 

achylia gastrica or exceedingly low degrees of hypochlorhydria or 
complete achlorhydria. Several of the cases referred or seen in con- 
sultation were originally, in fact, interpreted as carcinoma of the 
stomach, owing to the lack of gastric acid, the dyspeptic disturb- 
ances and. the profound anemia. 

Here then is a definite point of attack in the treatment of this Restoration of 
disease, viz., the restoration of nutritive equilibrium by artificial nutntlon 
means, and, by implication, the prevention, so far as that is possi- 
ble, of abnormal or excessive intestinal decomposition. The 
following method, after trials in various directions and the 
employment of different dietetic schemes, has proved itself to be 
most efficacious, leading, as will presently be shown, to a sympto- 
matic (?) cure within a very short time in the three cases in which 
it has so far been consistently tried. When I record that all the 
other patients with pernicious anemia who have come under my 
observation in the last five years, who were not treated in this 
way, are dead or not at all improved, the justification of this treat- 
ment will be recognized. 

The treatment consists in the incorporation of the maximal Proteid over- 
amount of proteins administered in conjunction with artificial di- 
gestants to facilitate their assimilation in the gastro-intestinal tract 
and their proper absorption from the bowel. The diet consists in an 
abundance of meat, fish, eggs, milk, buttermilk, administered by 
mouth in a finely divided form and fed in comparatively small 
quantities at frequent intervals; so that the patients instead of re- 
ceiving three large meals a day receive five or six smaller feedings in 
the course of the twenty-four hours. The selection of the particular 
kind of albuminous food and its mode of preparation depend some- 
what on individual peculiarities that must be studied in each case ; 
tastes and dislikes, cravings, idiosyncrasies. Meats are given in the 
form of broiled, roast and stewed preparations, never fried; or as 
meat juices, raw or slightly heated meat jellies, "peptones," gela- 
tins; eggs, preferably raw or soft boiled, in large quantities, each 
day, a dozen if possible ; milk and milk preparations of all kinds ad 
libitum, raw, boiled, as cottage cheese, or in combination with eggs 
as eggnog, etc. The addition of a little alcohol each day to the 
diet has been found of value rather on account of the food value 
and the "sparing" properties of the latter than on account of any 
stomachic or generally stimulating effect. Fats are given mod- 
erately, because, when administered in combination with abundant 
albumens, they are apt to coat the albuminous particles in the 
stomach and prevent contact with the artificial digestive juices to 
be administered. Enough cereals, bread stuffs and vegetables, 
fruits, all administered in a soft and finely divided form, are al- 
lowed in addition, to make up a palatable meal. 



154 DISEASES OF THE BLOOD 

Rectal feeding Such an over-diet in which albuminous foods predominate is 

given both by mouth and by rectum; per rectum in the form of 
predigested clysmata, together with sodium bicarbonate, a little 
sodium chloride and pancreas, with about 10 drops of laudanum 
(the latter to reduce expulsive peristalsis) ; by mouth, either in the 
same way (without laudanum), or, preferably by far, with very large 
quantities of hydrochloric acid. Here it is necessary to experiment 
a little. One must look on the stomach in these cases merely as a 
sac with no digestive function and generally with reduced propul- 
sive powers, and one can either administer hydrochloric acid with 
the object of artificially creating conditions that resemble the 
normal gastric digestion, or can ignore the gastric digestion alto- 
gether and by administering pancreas and an alkali, so to say, 
transfer intestinal digestion backward into the stomach. The for- 
mer plan, if it can be carried out, is by far the better for the HC1, 
in addition to being a powerful digestant of albuminous pabulum, 
acts as a deterrent to the development of an abnormal gastrointes- 
tinal flora. Pancreas-alkali, on the other hand, rather favors in- 
testinal putrefaction as indicated by definite urinary and fecal phe- 
nomena. The acid plan, moreover, more closely approximates the 
normal. The pancreas plan permits of a more liberal feeding, espe- 
cially of carbohydrates and fats, but I have found that the albumens 
count rather than the other food classes, so that in the particular 
class of cases under discussion nothing is gained by more food 
variety. 

The acid plan All of the patients reported below* were treated by the acid 

plan. They were given 10 to 15 drops of strong hydrochloric 
acid fifteen minutes after each feeding, and again thirty minutes 
after each feeding. It is useless to administer the dilute acid. Much 
prejudice is encountered, especially on the part of the druggist 
who fills the prescription, to the administration of such large quan- 
tities of strong hydrochloric acid, but no harm ever accrues from 
its use, provided enough albuminous pabulum is given at the same 
time. In order to prevent mouth irritation the acid is best given 
in mucilage water; I have never seen any advantage from the sim- 
ultaneous administration of pepsin, and consider it superfluous. 
Rectal clysmata of the character indicated above are given twice a 
day, or, if some rectal irritation results, only once a day. They 
are needed only in the beginning; that is, for a week or so. Oc- 
casionally a patient cannot tolerate them at all; in such a case it 
is best to omit them, only, however, after a persistent trial and after 
every attempt has been made to overcome the prejudice commonly 
existing against this form of feeding. 

Hospital treat- That this treatment should be begun in a hospital is self-evident. 

In the first place, the patients should be kept completely at rest in 
*See page 159 



ment 



DISEASES OF THE BLOOD 155 

bed; in the second place, a trained dietetitian is needed to prepare 
the food properly until the patient or his attendants have been 
taught how to prepare and administer the diet; in the third place 
the patient's blood condition, body weight and digestive function 
should be under daily control, so that the treatment may be ar- 
ranged to suit individual peculiarities that may be discovered. More 
than a three weeks' hospital sojourn is rarely needed. Improve- 
ment rarely becomes manifest before the tenth to the fifteenth day ; 
but from then on, in the cases observed so far, the improvement 
is rapid. There is often some discomfort in the beginning, and the 
hospital is the place to enforce persistence in a, somewhat strenuous 
and not altogether agreeable plan, especially as all of the patients 
have been very irritable and cranky in the beginning and quite diffi- 
cult to manage. And one of the most gratifying results observed 
early in the course of the treatment has been a change in their mood 
and spirits and disposition for the better as soon as proper nutri- 
tion was again fairly under way. 

Hydrotherapeutic measures, on account of the weakened con- Hydrotherapy 
dition of the patient, the impoverished state of the blood and the 
deficient vaso-motor reaction, had better be omitted, at least during 
the active stage of the disease. 

The best remedy to administer in pernicious anemia is arsenic. Arsenic 
This drug does not cure the disease, but it certainly aids in im- 
proving the condition of the blood, and hence in removing many of 
the most distressing symptoms that are attributable to the deficient 
nutrition of various organs, that results from the decrease of 
hemoglobin in the blood. Arsenic may be administered either in Dose and adr 
the form of Fowler's solution or as arsenious acid. It is best to n 111118 * 1 ** 1011 
begin with small doses, gradually increasing them, and to keep 
the patient for a time just below the maximum dose that has been 
reached ; then gradually to reduce the dose again. Some authorities 
advise beginning at once with large doses, but I have never been 
able to convince myself that this treatment is more efficacious or 
more rapid in its results ; in fact, I consider it occasionally danger- 
ous, in view of the possible idiosyncrasy of the patient against ar- 
senic and on account of definite contra-indications to its use that 
may not be discovered until the drug is being administered. 

Such contra-indications are the existence of dyspeptic symptoms Contra-indi- 
and of diarrhea before the drug is given, or their development soon u| e 10 <$f S areeaic 
after its exhibition. In all these cases arsenic should be discon- 
tinued until the diarrhea is checked or the dyspeptic symptoms are 
relieved. Sometimes, in very urgent cases, these contra-indications 
to the use of arsenic may be neglected ; care being taken that some 
measures are instituted that can counteract the bad effects that we 
must expect from the use of the drug ; thus arsenic given by mouth 



156 



DISEASES OF THE BLOOD 



Fowler's 
solution 



Asiatic pill 



Arseniated 

mineral 

waters 



Hypodermic 
administra- 
tion of ar- 
senic 

Cacodylate of 
soda 



with abundant quantities of fat is occasionally well borne; or the 
addition of opium to an arsenic preparation may sometimes effect- 
ually counteract the tendency to diarrhea. In treating patients in 
this way we are on the horns of a dilemma, and are simply choos- 
ing the lesser of two evils ; for it is often most important to use ar- 
senic, even though distressing symptoms are produced by its ad- 
ministration. 

If Fowler's solution is used one should begin with ten drops 
in water or milk, three times a day after eating, gradually increas- 
ing the quantity by a drop a dose a day, i. e., by three drops a day. 
As a rule, this increase can be borne for about ten days, i. e., until 
the patient is taking sixty drops during the twenty-four hours. 
Occasionally symptoms of arsenic poisoning appear before the max- 
imum dose is reached. The patients then complain of burning in 
the mouth, thirst, dyspeptic symptoms with eructations and pain 
in the epigastrium, some puffiness about the eyelids and the ap- 
pearance of red blotches in different parts of the body. When such 
symptoms appear, the dose of arsenic should at once be reduced and 
occasionally it may even become necessary to stop the drug alto- 
gether until these symptoms disappear. 

Arsenious acid is best given in the form of the so-called Asiatic 
pills, which contain some pepper. The latter stimulates the secre- 
tion of hydrochloric acid and aids in the rapid absorption of the ar- 
senic, thereby, in a measure, preventing injury to the gastric mu- 
cosa by the drug. One should begin with one such pill a day, grad- 
ually increasing the dose until six, or eight, or ten pills are taken a 
day. This latter dose corresponds to about sixty to seventy drops of 
Fowler's solution. 

Still another method of giving arsenic, in case neither Fowler's 
solution nor arsenious acid can be borne, is to use arseniated min- 
eral waters. A number of these waters are on the market (Lithico 
water, Eoncegno, la Bourboule, Guberquelle and others). Most of 
these contain very small quantities of arsenic combined, as a rule, 
with iron. They should be administered at first in small quantities, 
preferably in tablespoon doses, gradually increasing the amount un- 
til a wine glass full, two or three times a day, is being taken. Their 
composition, however, is not constant and one is never sure of an 
arsenic effect when giving these waters. 

The hypodermic administration of arsenic is not to be advised 
in pernicious anemia, for disagreeable local symptoms are very apt 
to appear. The only arsenic preparation that can be given with 
safety is the cacodylate of sodium, in the strength of 1 to 500, in 
10 cc. doses, once or twice a day. I have had the impression, how- 
ever, that this method of administering arsenic, useful though it 
may be in certain other conditions, notably chorea and leukemia, is 



DISEASES OF THE BLOOD 157 

of very subordinate value in pernicious anemia, and certainly in- 
ferior to the administration of arsenic by mouth. 

Iron is not indicated in pernicious anemia. My opinion is that iron not indi- 
it does more harm than good, for it seems to exercise no effect upon cated 
the constitution of the blood, while it usually irritates the stomach 
and disturbs the digestion. 

Cholesterin has recently been recommended in desperate cases. Cholesterin 
The administration of this drug, however, dissolved as it must be in 
warm oil, is rather difficult and, in so far as it is contained in many 
of our articles of diet as yolk of egg, butter, brains and cod liver 
oil, one may be persuaded to administer it in this form rather than 
in the pure form. 

Bone marrow was, at one time, employed in the treatment of Bone marrow 
pernicious anemia, but its use is being abandoned. I have never 
seen any good results from its exhibition. The same applies to 
the administration of dried blood or hemoglobin in solution by Hemoglobin 
mouth or per rectum. 

The patients should have some thyroid extract, in doses varying Thyroid 
from three to five grains of the extract, three times a day, by 
mouth or with the clysma by rectum. I am under the impression 
that the administration of thyroid materially aids in the assimila- 
tion of proteins. 

In every advanced case of pernicious anemia, in which the pa- Transfusion 
tient is in imminent danger of his life, transfusion of blood from a blood* 1 
healthy subject, or of physiological salt solution, or the injection 
of the latter by hypodermoclysis, are exceedingly useful measures. 

The transfusion of blood from a healthy individual to the pa- Technique of 
tient should be performed as follows: A compression bandage is transfusion 
applied about the arm, both of the healthy individual and of the 
anemic subject and the anterior surface of the arm of each thor- 
oughly cleansed with soap and water, 1 to 1,000 bichloride solution, 
alcohol and ether; a hollow needle connected with a thin rubber 
tube is now inserted into a vein of the healthy subject and about 
50 cc. of blood aspirated with a syringe. At the same time an as- 
sistant inserts a similar needle connected with a rubber tube into 
the vein of the patient, allowing a few drops of blood to ooze out 
of the tube, and then rapidly connects it with the syringe contain- 
ing the blood from the healthy subject. This blood is now slowly 
injected into the veins of the patient, and the operation repeated 
four or five or six times in the course of five to twenty minutes. 
That everything should be rigidly sterile need hardly be mentioned. 
It is always safer to have a number of syringes ready, so that a new 
syringe can be used for each transfusion, otherwise there is always 
danger of coagulation occurring in the syringe or its nozzle, with 
the possibility of forcing a fibrin coagulate into the veins of the 



158 



DISEASES OF THE BLOOD 



Indirect meth- 
od of trans- 
fusion 



Disagreeable 
sequelae fol- 
lowing trans- 
fusion 



Results 



Transfusion 
of normal salt 
solution 



Hypodermo- 
clysis 



patient; such an accident would, of course, be fraught with very 
serious consequences. This method of transfusion is called the 
direct method. 

Transfusion of very small quantities of dehbrinated blood not 
to exceed 5 cc. is often followed by remarkably good results in a 
few cases. In the beginning general toxic symptoms — fever, head- 
ache, dizziness, tinnitus generally appear, but they are negligible, 
in view of the benefits that one may expect occasionally from this 
therapy. 

There is also an indirect method. It is more complicated, less 
safe and not so easy of execution. It consists in withdrawing about 
400 cc. of blood from the normal subject by venesection, rapidly 
defibrinating this blood by beating it with a glass rod, filtering off 
the clot and injecting the plasma through an ordinary transfusion 
apparatus into the veins of the patient. In performing this opera- 
tion the canula leading from the transfusion apparatus must be 
tied into a vein in the patient's arm. This requires dissecting out 
the vein, a manipulation that calls for considerable skill and most 
rigid asepsis, and that, besides, is more painful than the insertion 
of a canula or trocar needle directly into the vein. 

Many patients react to this transfusion by a chill, a rise of 
temperature and sweating, all symptoms that are presumably due to 
a ferment intoxication. Sometimes during the injection of blood 
the patient becomes cyanotic and dyspneie ; these are indications to 
stop the infusion of blood. 

The results obtained from this practice are exceeding variable; 
some patients improve immensely at once, in others no effect what- 
soever is observed, and in still others the disagreeable consequences 
enumerated above make their appearance. A few deaths have been 
known to follow transfusion. The method nevertheless should, at 
all events, always be given a trial, especially when the cases are in 
so desperate a position that any measure, however dangerous it 
may be, becomes justifiable. 

Next in importance to the transfusion of blood is the transfu- 
sion of normal salt solution, containing about 0.8 per cent of so- 
dium chloride to a liter of water; or this salt solution can be in- 
jected under the skin as follows : The sterile solution is poured into 
a fountain syringe that is elevated about two or three feet above the 
bed; the fountain syringe is connected with a rubber tube that 
branches out into two ends each connected with a hollow needle ; the 
two needles are inserted either into the skin of the thigh or of the 
abdomen or into the pectoral fascia underneath the breasts. From 
one to two liters of the solution may be injected in the course of 
from ten to fifteen minutes, care being taken that the region into 
wiiich the fluid is injected is massaged during all the time the so- 



DISEASES OF THE BLOOD 159 

lution is flowing; this greatly facilitates the absorption of the salt 
solution. This method is quite painful and occasionally requires 
chloroform narcosis. The results obtained from saline solution 
are not so favorable by far as those obtained from the transfusion of 
normal human blood. 

During the periods of remission the patients should continue Treatment 
the use of small doses of arsenic. They should live on a nourish- s i ons 
ing diet similar to the one described above, and should preferably 
seek a resort with a moderately temperate climate, with the maxi- 
mum of sunshine and clear days, where they can lead an out-of- 
door existence, preferably at a moderate altitude, not exceeding 
three thousand feet. 

Sooner or later in the disease the condition will become aggra- 
vated again, provided the anemia is not due to intestinal parasites. 
As soon as the condition of the blood becomes bad and the patients 
grow weak again, they should at once be put to bed and energetic 
treatment immediately instituted. 

Symptomatic treatment is synonymous with the treatment of Symptomatic 
the organs whose function becomes deranged; thus the gastro- 
intestinal, the cerebral symptoms, the symptoms about the heart, 
the hemorrhages, should be treated as described in other sections. 

In interpreting therapeutic results in any case of pernicious Interpretation 
anemia, the greatest conservatism should be observed in two direc- °* results 
tions ; namely, first, one should be altogether sure that one is deal- 
ing with a true pernicious anemia and not with a severe degree of 
simple anemia; second, one should be quite certain that any ap- 
parent improvement is not merely one of the spontaneous remis- 
sions that occur in so characteristic a manner in this disease, and 
quite independently of any treatment that may have been instituted. 

The following case reports may illustrate the efficacy in some cases 
of the plan of treatment outlined above: 

Case 1. — Mr. K. M. M., referred by Dr. C. H. Wallace, of St. Joseph, Case reports 
Mo. Age 54. History of gastro-intestinal disturbances extending over 
several years. Rapid loss of flesh during last year. Entered Michael 
Reese Hospital Nov. 2, 1908. Pale, anemic, slightly edematous skin. 
Slight albuminuria, a few hyaline and granular casts. Temperature on 
admission 99.4 F. Gastric analysis after Ewald test meal show com- 
plete achylia gastrica without motor insufficiency. Blood analysis: 
Hemoglobin 30 per cent., red b.c. 1,180,000, white b.c. 7,400. Differential 
Count: Neutrophiles 67% per cent., lymphocytes 30 per cent., large 
mononuclears 0, eosinophils 1 per cent, transitonals 1.5 per cent. Red 
Cell Morphology: Poikilocytosis, megalocytes, microcytes, megaloblasts, 
microblasts, a few nucleated red cells, polychromatic degenerations. 
Weight on admission, 132% pounds. 

Treatment instituted as above. Left hospital after three weeks, 
Nov. 23, weighing 137% pounds, a gain of five pounds. Albumen and 
casts disappeared from urine. No edema. Color, strength and spirits 
greatly improved. Blood Analysis: Hemoglobin 65 per cent., red blood 
count 2,600,000. No megaloblasts or microblasts, a few nucleated red 



160 DISEASES OF THE BLOOD 

cells; poikilocytosis still present but less marked. Treatment continued 
conscientiously at home with steady improvement in general strength, 
and resumption of daily duties. 

The following was the report of the blood examination at the expira- 
tion of 10 weeks: Hemoglobin 85 per cent., red b.c. 4,400,000, white b.c. 
8,400. No abnormal red cells. No poikilocytosis. Increase in weight. 
Report on Feb. 9, 1910: "I am as good as ever." Weight in May, 1910, 
147% pounds. 

The patient still continues the use of large doses of hydrochloric 
acid and is instructed to persist in its use indefinitely. 

Case 2. — Mrs. K. L, C, Kansas City, Mo. Age 49. Seen first with 
Dr. Golden at Mercy Hospital and referred to Michael Reese Hospital 
Sept. 14, 1909. History of increasing weakness, severe digestive dis- 
orders and great loss of weight within a year. Patient in a state of 
profound prostration and unable to be out of bed. Exceedingly pale and 
slightly edematous skin. Slight albuminuria without casts. Tempera- 
ture on admission 100.2 P. 

Gastric analysis after Ewald test meal showed complete lack of 
hydrochloric acid, very slight peptic power and a little blood. No motor 
insufficiency. Blood Analysis: Hemoglobin 30 per cent., red b.c. 
1,384,000, white b.c. 6,800. Differential Count: Neutrophils 72 per cent, 
lymphocytes 22 per cent., large mononuclears 2 per cent., eosinophiles 2 
per cent., transitionals 2 per cent. Red Cell Morphology: Poikilocytosis, 
many megalocytes and microcytes, a few megaloblasts, polychromatic 
degeneration types. The weight of the patient on admission was 119 
pounds. 

Treatment as described above. Discharged from hospital after four 
weeks, weighing 133% pounds; i. e., a gain of 14% pounds. Albumin 
disappeared from the urine. Skin color florid and no edemas. Almost 
normal strength. Blood Examination: Hemoglobin 60 per cent., red 
b.c. 3,400,000. No megalocytes or megaloblasts or polychromatophilia. 
Slight poikilocytosis. White count 9,100, differential normal. Referred 
to Dr. Logan Clendening of Kansas City, Mo. Report from the latter 
Oct. 26, 1909: Hemoglobin 85 per cent., red b.c. 3,500,000. On Dec. 27, 
1909: Hemoglobin 100, red cells 4,400,000. No abnormal morphology. 
Weight on Oct. 26, 1909, 146 pounds. This weight has been maintained 
to date, as well as the normal blood condition. 

The following report was received from the patient in May, 1910: 
"I feel splendid, sleep well and have a good appetite. However, I am 
still taking the hydrochloric acid and would like to have you toll me if 
I must take it during the remainder of my natural existence." This 
query was answered in the affirmative. 

Case 3. — Mr. J. B., referred by Dr. I. C. Smith, of Stockton, 111. Age 
46. Entered Michael Reese Hospital Sept. 1, 1909. History of loss of 
strength and rapid loss of weight for the last seventeen months. Pa- 
tient exceedingly weak, very pale and slightly edematous. Slight albu- 
minuria and numerous hyaline and a few blood casts. Severe gastric 
distress with loss of appetite and nausea. Temperature on admission 
100.4 F. 

Gastric Analysis: Total acidity 9. Free hydrochloric acid absent. 
Slight degree of motor insufficiency. Slight peptic power. A few red 
blood corpuscles were found in the stomach contents. 

Blood Analysis: Hemoglobin 40 per cent., red b.c. 1,800,000, white 
b.c. 8,200. Differential count normal. Red Cell Morphology: Severe 
polikilocytosis, megaloblasts, microblasts, megalocytes and microytes, 
nucleated reds and polychromatophilia. Weight on admission 135 
pounds. 

Treatment as above. Discharged from hospital Oct. 2, 1909 — i. e., 
after about four weeks — weighing 155% pounds, a gain of 22% pounds. 
Blood Analysis: Hemoglobin 75 per cent., red b.c. 2,400,000. Poikilocy- 
tosis slight and no other abnormal red cells. 

Treatment continued at home with progressive gain in weight and 
strength and resumption of farming duties. Patient reported on May 
12, 1910, weighing 157 pounds, and with an altogether normal bloo^ 
picture. 



DISEASES OF THE BLOOD 161 

SIMPLE ANEMIA. 

Simple anemia is always a symptom of some underlying dis- Indications 
order, hence the treatment, broadly speaking, is synonymous with . r treating 
the treatment of the cause that produces the impoverishment of the anemia 
blood. Every effort, therefore, should be bestowed upon finding this 
cause and removing it. Occasionally, however, simple anemia per- 
sists even when the underlying cause is removed, as, for instance, 
the anemia developing after internal or external hemorrhages, pro- 
fuse vomiting, pregnancy, intoxication by intestinal parasites and 
various infectious diseases. In all of these cases the resulting ane- 
mia would, in all probability, heal spontaneously in time, but never- 
theless it often becomes necessary to aid Nature in its reparative 
endeavors as otherwise serious nutritional disorders would de- 
velop in different organs. 

Again, the disease which produces the anemia may be very 
chronic in character, so that while the cause of the anemia is 
known it may be difficult or impossible to remove it. This applies 
particularly to the simple anemia seen in tuberculosis, in chronic 
suppurative processes, after prolonged lactation, in malnutrition 
due to stenosis of the esophagus or organic diseases of the stomach, 
in nephritis, syphilis, chronic malaria and in various forms of 
chronic poisoning. Here the anemia attains almost the dignity of 
an independent affection and urgently calls for special treatment. 
It is well to realize that in anemia due to chronic disorders of an 
irremediable character it is usually impossible to completely re- 
store altogether normal conditions in the blood. Very much, how- 
ever, can be done in this direction and no effort should, therefore, 
be spared to attain the best possible conditions. 

In the treatment of anemia the regulation of the diet is a very Diet 
important element. It is clear that every effort should be advanced 
to maintain nutritive equilibrium, that is, to supply an amount of 
food sufficient to enable the organism to put forward its best ef- 
forts towards producing the regeneration of the blood. This can 
never be accomplished if the patient is chronically underfed. Unfor- 
tunately, in simple anemia the gastro-intestinal function is fre- 
quently perverted. This must be attributed to the malnutrition (re- 
sulting from an inadequate blood supply) of the gastric and intes- 
tinal glands and of the nerves supplying them. For this reason it is 
a matter of great importance in arranging a dietary for an anemic 
case to carefully study the condition of the gastric function by 
means of test-meals and according to methods described in the 
Chapter on Diseases of the Stomach. The diet should then be ac- 
commodated exactly to the functional powers of the stomach and 
intestine. 



162 



DISEASES OF THE BLOOD 



Much albumen 



Rectal feeding 



Lack of appe- 
tite 



Rest 



Management 
after hem- 
orrhages 



Broadly speaking, the diet should contain an abundance of al- 
buminous food. In cases of hyperchlorhydria this regulation is, of 
course, very easy to carry out. If there is a lack of hydrochloric 
acid, then the latter must be supplied if an albuminous diet is ad- 
ministered. Meats of all kinds, preferably raw or rare, fish, game, 
eggs, milk are all very useful articles of diet. In addition there 
should be plenty of fresh fruits and vegetables. Whether or not 
it is of advantage to give foods that contain relatively large quan- 
tities of iron is doubtful, because the amounts of iron contained in 
these foods can be more readily supplied medicinally ; nevertheless, 
yolk of egg, spinach, apples and all articles that contain relatively 
large amounts of iron may without harm be liberally supplied. 
Carbohydrate foods, that is, cereals, bread, rice, potato, sweets 
should be given sparingly and fats should be given in moderation. 

If the anemia is primarily due to some gastro-intestinal dis- 
order, then exceptional care must, of course, be exercised in select- 
ing a diet. This applies particularly, to cases of anemia developing 
upon the basis of gastric or intestinal hemorrhage from ulcer. Here 
it may become necessary to put the stomach completely at rest for 
a time and to feed the patient exclusively by rectum. The technique 
of rectal feeding is fully described under Stomach Diseases. 

Proper feeding in anemia is often rendered difficult because many 
patients with simple anemia suffer from lack of appetite. This 
element can usually be corrected by the use of bitter tonics, as 
tincture of cinchona, in doses of one to two drachms; tincture of 
nux vomica, five to twenty drops ; compound tincture of cardamom, 
one to two drachms ; or orexin, in five grain doses. Very often ane- 
mic patients are benefited by drinking on rising, and fifteen to twen- 
ty minutes before each meal, a glass of hot water containing one- 
third of a teaspoonful of bicarbonate of soda. 

In severe cases of anemia rest, bodily, mental and psychic, is 
of the greatest importance. In the anemia following severe hem- 
orrhage, either internal or external, rest in bed is absolutely es- 
sential. Here the limbs should be elevated and the head placed 
low so that blood, at all events, will reach the brain and the vital 
centers in the medulla. After the bleeding has been stopped, it 
often becomes necessary in patients who are very much exsanguin- 
ated to perform transfusion of normal salt solution, as described 
on a preceding page. If the facilities for transfusion are not im- 
mediately available, then what may be called auto -transfusion 
should be practiced. This consists in wrapping bandages around 
the extremities, beginning at the distal end and wrapping towards 
the center. These bandages can be left in place for one or two 
hours. In this way enough blood is forced to the head, the medulla 
and the heart to sustain life; at the same time the patient should 



DISEASES OF THE BLOOD 163 

receive large amounts of water by rectum and, if he is conscious, by 
mouth. If collapse or heart failure threaten, then enemata contain- 
ing alcohol (about two tablespoonfuls to the quart), or subcu- 
taneous injections of ether or camphorated oil or of a 10 per cent, 
solution of camphor in ether, should be given. If necessary trans- 
fusion may be practised several times. 

Cases of chronic anemia are very susceptible to temperature 
changes. This is due to the deficiency of hemoglobin in the blood, 
to the reduction of oxidative processes and hence impaired manu- 
facture of heat and to the instability of the vaso-motor centers. Con- 
sequently anemic cases are particularly liable to catch cold, so that 
great care should be exercised in selecting sufficiently warm cloth- 
ing and the proper foot-wear. Inasmuch as the loss of heat from Clothing and 
the surfaces of the body is best prevented by creating an immovable 
layer of air between the skin and the first garment, a material 
should be selected that is a poor conductor of heat, that rapidly 
absorbs perspiration from the surface of the body and permits slow 
evaporation of the absorbed moisture. The ideal material is wool, 
for the fine hairs that are contained in wool garments effectively 
keep the clothing at some distance from the skin, while, at the 
same time, the rough character of the wool produces some irrita- 
tion and friction of the skin and hence a slightly hyperemic condi- 
tion which is grateful to anemic patients. The roughness of wool 
garments stimulates perspiration, but the porous character of wool 
causes rapid absorption of the moisture exuded from the sweat 
glands, while, at the same time, the sweat evaporates very slowly 
from the outer surface of the material; hence wool garments do not 
become saturated with moisture nor do they cling to the skin, so 
that they adequately protect the organism against loss of heat. In 
summer flannel and silk are less irritating to the skin and, at the 
same time, serve a useful purpose as bad conductors of heat. Linen 
and cotton underwear should never be worn by anemic patients. 
The foot-wear should be thick and the patient should wear woolen 
stockings during winter. 

On account of the susceptibility of anemic patients to tempera- Bathing 
ture changes and particularly to cold, cold bathing should be ab- 
solutely forbidden. Even in neurasthenic and hysterical cases the 
use of cold or cool hydrotherapeutic measures that are otherwise so 
useful should be interdicted. Sea bathing is also absolutely detri- 
mental to these cases. Hot baths, however, are very grateful and 
exercise a distinctly stimulating effect upon the metabolism, upon 
the circulation and upon the regeneration of the blood ; they should 
therefore be advised. 

If anemic patients are to select a climate or a resort they Cliniate and 
should be sent to a moderate altitude, for a low barometric pres- 1 u e 



164 



DISEASES OF THE BLOOD 



Medicamen- 
tous treatment 
Iron and ar- 
senic 

Contra-indica- 
tions for the 
use of iron 
and arsenic 



Rectal and 
hypodermic 
administra- 
tion 



sure stimulates blood regeneration. That the climate should be 
warm and that there should only be slight temperature changes is 
self-evident. 

The drug treatment of simple anemia consists chiefly in the use 
of iron and arsenic. There are, however, frequently very distinct 
contra-indications to the use of both these remedies; thus neither 
iron nor arsenic should ever be given if there are severe gastro- 
intestinal disorders, because both of these drugs, without question, 
have a tendency to irritate the stomach and the intestine. Nor 
should iron be administered to cases of anemia suffering from pul- 
monary tuberculosis. I believe that it occasionally aggravates the 
condition of these patients and even stimulates a latent or quiescent 
tuberculous focus in the lungs to renewed dangerous activity. It 
also occasionally seems to produce a rise of temperature. Trousseau 
claims to have seen pulmonary hemorrhage develop after the ad- 
ministration of iron in pulmonary tuberculosis. This observation 
has repeatedly been corroborated. I have never, personally, been 
able to convince myself of its truth. Arsenic is contra-indicated 
also in cases suffering from nephritis, for when the kidneys are dis- 
eased they eliminate the drug with difficulty and there is always 
danger both of irritating the diseased renal epithelia and of pro- 
ducing a cumulative arsenic effect. 

Gastro-intestinal disorders, therefore, should always first be 
treated and, if possible, cured, before iron or arsenic are given by 
mouth. In the meantime, both remedies may be administered by 
rectum, the iron in the form of dried blood or of reduced iron, or 
of tincture of the chloride of iron; arsenic preferably in the form 
of Fowler's solution as follows : 

Sol. arsenic. Fowleri. 10.0 

Tinct. chinae comp. 20.0 

M. S. 5 drops in water t. i. d. 
Increase until 12 drops t. i. d. are taken. 

Arsenic may also be administered hypodermically in the form 
of the cacodylate of soda, or as atoxyl, as follows: 

Atoxyl 1.0 

Aq. dest. 10.0 

M. S. 1 cc. to be injected three times a week. 

This course to be repeated after a few weeks' pause. 

A very convenient method of overcoming the pain that fre- 
quently accompanies intramuscular or subcutaneous injections of 
atoxyl is the following: 



DISEASES OF THE BLOOD 165 

An ordinary Pravaz syringe is filled to about 4/5 its volume Painless atoxyl 
with a warm 20 per cent, atoxyl solution, the tip of the syringe is 
then dipped into a 1.5 per cent, solution of eucaine muriate or 
lactate and the piston completely withdrawn so that the lower fifth 
of the syringe is filled with the eucaine solution. If proper care is 
exercised, the two fluids do not mix. The needle is then inserted 
as vertically as possible into the gluteal or deltoid muscles, the pis- 
ton pushed down until the lower part of the syringe containing 
the eucaine solution is emptied, then, after a pause of a minute, 
the balance of the contents of the syringe, consisting of the atoxyl 
solution, is injected in two or three installments. In this way no 
pain is felt during the injection nor afterwards. 

In administering arsenic, the peculiarities and idiosyncrasies Method of ad- 
of the case must be carefully considered and the tolerance of each j^^nic^ 8 
individual patient for the drug first carefully established. It is 
best, therefore, always to begin with small doses of arsenic and 
gradually to increase the quantity until the limit of tolerance is 
reached; to keep the patient for several weeks upon a quantity of 
arsenic slightly below this dose; and then to gradually reduce the 
dose again. Tor other details relating to the administration of 
arsenic, see Pernicious Anemia. 

In administering iron it is important to remember that the Method of ad- 
patient should receive about 0.0.1 gm. of iron per day. The exact j™ n 1 lstenng 
preparation of iron used is immaterial. Personally, I prefer re- 
duced iron or the tincture of the chloride of iron to any of the or- 
ganic preparations, for by employing simple inorganic products the 
dose can be much more accurately gauged. Iron and arsenic waters 
can also be employed in the treatment of simple anemia. 

It is best, in all cases of simple anemia, even after normal con- 
ditions in the blood have been re-established, to continue the use of 
small doses of arsenic and iron, e. g., from three to ten drops of 
Fowler's solution and two to six grains of reduced iron a day, for 
several months. 



CHLOROSIS. 

The most characteristic feature of chlorosis is the reduction Definition 
of the hemoglobin in the individual red cells, combined with an in- 
crease of the blood plasma without any appreciable reduction in 
the specific gravity of the latter. The underlying taint seems to be 
more a perversion of lymph formation than of blood formation. 
There is no anatomical evidence of disease of the blood-forming 
organs nor are there very marked quantitative changes about the 
red blood corpuscles or the leucocytes, nor generally any signs of de- 
generation of the latter. 



166 



DISEASES OF THE BLOOD 



The neurosal 
element 



Causal treat- 
ment 



Symptomatic 
treatment 



Rest 



Hydrotherapy 



We are justified in assuming that in chlorosis the interchange 
of the fluids between the blood and the tissues is altered (witness 
the great frequency of puffiness and edema), and this anomaly can 
best be explained by assuming a vasomotor neurosis as the under- 
lying cause. A strong neurosal element, moreover, enters into the 
clinical picture of chlorosis, manifesting itself not only about the 
vaso-motors of the body (remark the abnormal tendency to blush- 
ing and sudden pallor) , but also in a variety of other manifestations 
that closely simulate the picture of hysteria. When we consider, 
finally, that the disease is most common in young girls during 
the period of adolesence, that it is frequently coupled with a variety 
of menstrual disorders, psychoses, perversions of the appetite, the 
sense of smell and taste and various secretory anomalies, we are 
justified in instituting causal treatment in chlorosis, more against 
the underlying neurosis than against the condition of the blood 
alone. The causal and prophylactic treatment, therefore, should 
concern itself chiefly with improving the general and personal 
hygiene of the patients, in properly feeding them, and in combating, 
with all the means at our disposal, the psychic and neurotic ele- 
ments that so often predominate in this disorder. 

The symptomatic treatment should be directed towards cor- 
recting the abnormal condition of the blood, and, by implication, 
towards relieving symptoms in various organs attributable to func- 
tional disturbances that are superinduced largely by the malnutri- 
tion either of the organs themselves or of the nerves supplying 
them. 

One of the most important elements in the treatment of chlorosis 
is rest. The patients should be put to bed and kept there for several 
weeks at a time. If possible, they should be removed from their 
home surroundings and treated either in an institution or in some 
resort where they can enjoy a change of scene and can carefully 
follow the directions of the physician during the period of conva- 
lescence. Kemoval from home alone, combined with rest, often 
effects a cure. 

Combined with rest in bed certain hydriatic measures are of 
great use. Best of all are wet packs administered by wrapping the 
patient every morning in a linen sheet wrung out of warm water 
(90-96° F.) and allowing them to lie in this compress, covered 
with woolen blankets, for about half an hour. 

All hydrotherapeutic measures of a soothing character in fact 
are of great value and can usually be carried out without difficulty 
at home. Three times a week, e. g., in the forenoon a bath of about 
40° C. should be administered, the patient remaining in the water 
for ten minutes in the beginning and later for twenty minutes, care 
being taken that the temperature remains at the same level. After 



DISEASES OF THE BLOOD 167 

leaving the bath, the patient should be rubbed dry with a rough 
towel and jmt to bed for about an hour. In the beginning of this 
treatment the patients often complain of a feeling of great lassitude, 
objectively made manifest by an increase in the pulse rate, some 
arhythmia and palpitation. These disagreeable symptoms, how- 
ever, rarely persist longer than the third or fourth bath and after 
this marked improvement is usually noticed. 

Mild massage of the extremities and the abdomen is also ex- Massage 
ceedingly useful, both on account of its soothing effect on the ner- 
vous system and on account of its tendency to improve the circula- 
tion of lymph and hence promote the absorption of edemas. 

In many cases of chlorosis there are secretory disorders of Diet 
the stomach and not uncommonly muscular atony; thus gastro- 
ptosis, from relaxation of the abdominal muscles, is frequently 
combined with dilatation of the stomach from atony of the gastric 
walls. Stomach disorders are so common that some authorities Gastric dis- 
have attributed the syndrome of chlorosis to the digestive per- orders 
versions. It is more probable, however, that the stomach disorder 
is either a part symptom of the general neurosis, or is directly at- 
tributable to the malnutrition of the gastric walls, and the gastric 
glands, that results from the deficiency of hemoglobin in the blood. 
In each case of chlorosis a careful analysis of the stomach con- 
tents should be repeatedly made and the diet arranged accordingly, 
as outlined in the Chapter on Diseases of the Stomach. 

The use of hydrochloric acid for the dyspeptic disturbances of Abuse of HC1 
chlorosis is to be discouraged; for in nearly all cases of chlorosis 
the total acidity is either far above normal or at least normal, and 
rarely is any hypoacidity that might call for the administration of 
hydrochloric acid discovered. The dyspeptic disturbances of chlo- 
rosis (provided an ulcer is not present) are generally negligible as 
far as any specific treatment is concerned, and as a rule yield to the 
improvement in the general condition and in the composition of 
the blood. 

It is due to the variable character of the secretory perversion of Abnormal 
the stomach also that chlorotic girls so frequently develop abnormal 
cravings; some seem to crave acids, others enjoy eating chalk, and 
it does not appear improbable that this is Nature's method of at- 
tempting to neutralize the lack of hydrochloric acid on the one 
side, or to counteract hyperchlorhydria on the other. Unless there 
is marked hypersecretion or hyperchlorhydria calling for a proteid 
diet and antacid medication, chlorotic patients do best on a diet 
consisting largely of vegetables and containing the minimum of 
meat. 

This regime is particularly useful because in most cases there Constipation 
is also atony of the intestinal walls with very obstinate constipation. 



168 



DISEASES OF THE BLOOD 



Medicamen- 
tous treatment 



Iron 



Mode of action 



Theories in re- 
gard to the 
action of iron 
in chlorosis 



This frequent occurrence of constipation has led to the theory that 
chlorosis is due to stasis of bowel contents and abnormal putrefac- 
tion in the intestine, in other words, that it is an auto -intoxication 
from intestinal poisoning. Here, again, it seems more probable 
that the constipation is the result, and not the cause, of the chlo- 
rosis, for many cases develop without bowel symptoms and consti- 
pation is more frequently secondary to the chlorosis than vice versa. 

The exact selection of the diet must therefore depend largely 
upon the shifting peculiarities of each individual case. Broadly 
speaking it should be nutritious and easily digestible, it should 
meet the state of the gastric and intestinal function and should 
above all take into consideration personal idiosyncrasies of the pa- 
tient; for lack of appetite is one of the most distressing complica- 
tions of the disease. One should never force a chlorotic to eat 
food that is distasteful, nor should one generally forbid indulgence 
in articles that the patients crave but that are otherwise harmless. 
If this liberal plan is adopted, co-operation on the part of the pa- 
tient is always most readily secured. 

The medicamentous treatment of chlorosis calls chiefly for iron, 
but this remedy can in no way be considered a specific for the dis- 
ease, although it has frequently been so considered ; for many cases 
of chlorosis get well without iron, provided the general treatment 
outlined above is carefully carried out; and, on the other hand, 
many cases of chlorosis fail altogether to respond to iron treatment 
alone. Iron, nevertheless, is by far the best remedy we possess in 
the treatment of chlorosis, and as it never does any harm it should 
be given in every case. 

The mode of action of iron in chlorosis is very difficult to un- 
derstand. Some of the iron is undoubtedly absorbed into the blood, 
but most of it is wasted in the stools; of the assimilated iron a 
part is built up into hemoglobin, a part stowed in the liver and 
spleen. One can hardly say that in chlorosis there is a deficit 
of available iron in the food and that the administration of iron 
by mouth supplies this deficit. The iron must rather be con- 
sidered as a stimulant to the blood-forming organs. Bunge has 
advanced the theory that iron acts by combining with the sul- 
phureted hydrogen that is generated by the putrefaction of albu- 
mens in the bowel, forming insoluble iron sulphid, and in this 
way protecting the organic iron compounds of the food and render- 
ing them available; but there is little tangible evidence to show 
that this theory is correct; for, otherwise, any of the heavy 
metals that can combine with sulphureted hydrogen to form 
heavy sulphids should fulfill the same purpose, and this is not 
the case. Still others imagine that the iron, owing to its astringent 
properties, stimulates the gastro-intestinal mucosa to increased 



DISEASES OF THE BLOOD 169 

activity and hence improves nutrition. Immaterial what the 
theoretical indications for the use of iron preparations in chlorosis 
may be, the empiric fact remains that it is, in most cases, the 
sovereign remedy that can improve not only the condition of the 
blood, but also all the other disagreeable phenomena that compli- 
cate the disease picture of chlorosis. 

It is difficult to decide whether so-called organic or inorganic Choice of iron 
preparations of iron are more useful. Personally, I have P re P ara lons 
never seen any reason to use other than the ordinary inorganic 
preparations, for there is no evidence to show that the numerous 
organic preparations of iron are either more rapidly absorbed 
or less irritating to the gastro-intestinal tract, or clinically more Organic and 
effective than the inorganic preparations. As a matter of fact, Compounds of 
any iron preparation is converted in the stomach into the chid- iron 
ride; this usually combines with albuminous material to form 
an albuminate of iron, which, passing into the duodenum, is in 
part, as shown above, absorbed and deposited in the spleen 
and liver for future use, while the bulk is eliminated in the 
stools. 

The best iron preparation of all is Bland's pill, containing Blaud's pill 
sulphate of iron and the carbonate of potash. This pill acts 
beneficially, first, on account of the iron carbonate it incorpor- 
ates, second, presumably, on account of the potassium it con- 
tains, for the latter is an important constituent of the red blood 
cells, and, finally, on account of its content of sulphuric acid 
which readily combines with toxic aromatic products derived 
from putrefactive processes in the bowel, converting them into 
non-toxic aromatic sulphates (indican and its congeners). The 
tragacanth, finally, that these pills incorporate possesses some laxa- 
tive property which is useful. One to four pills of one grain each 
may be given two or three times a day, preferably after eating. It 
is usually best to begin with small doses, say one pill three times 
a day, and then to gradually increase the dose until four or five 
pills are taken three times a day. 

Another excellent iron preparation is the tincture of the Perchloride 
perchloride of iron, which may be given in doses of from five to 
fifteen drops three times a day. This medicine should always be 
taken through a tube in order to protect the teeth. Reduced 
iron, in doses of one to five grains (0.05 to 0.3 gm.) in capsule, Reduced iron 
is also a ver}- useful inorganic preparation. 

It is impossible to enumerate all the other preparations of 
iron that might be used. The three named above usually ful- 
fill all the requirements. The pill of aloes and iron may be Pill of aloes 
mentioned, because it is particularly useful in chlorosis com- and iron 
plicated with constipation. This pill contains sulphate of iron, 



170 



DISEASES OF THE BLOOD 



Citrate of iron 
and quinine 



Organic prep- 
arations 



Ferratin 
Carniferrin 

Hemoglobin 

Peptonates of 
iron 

Iron and man- 
ganese 



Contra-indi- 
cations to the 
use of iron 



the proper dose being four to eight grains three times a day. 
Another valuable official preparation is the citrate of iron and 
quinine, containing liy 2 per cent, of quinine and 14^ per cent, 
of iron, and given in doses of five to ten grains two or three times 
a day. The quinine in this pill is useful especially in cases that 
are characterized by great nervous asthenia, for the quinine un- 
doubtedly acts as a cerebral tonic. 

Among the organic preparations the following may be enu- 
merated, although, as stated above, none of them, in my opinion, 
possesses any advantage over the inorganic preparations, none 
is so reliable, so stable or so inexpensive. Ferratin, in doses of 
from eight to twenty grains (0.5 to 1.3 gm.) per diem. Carni- 
ferrin, containing 35 per cent, of iron and combined with sarcinic 
acid, and given in doses of from five to ten grains (0.3 to 0.6 
gm.) three times a day. Hemoglobin itself may also be used. 
The various albuminates and peptonates of iron possess no par- 
ticular advantages. The administration of iron in combination 
with manganese is no more effective than the administration of 
iron alone, although extravagant claims have been made for this 
therapy. 

There are certain contra-indications to the use of iron and 
there is occasionally difficulty in administering it; thus in very 
severe dyspeptic disorders, such as we not uncommonly see in 
chlorosis, iron occasionally aggravates the gastric symptoms. In 
such cases the dyspepsia should first be treated, as described 
in the Chapter on Diseases of the Stomach, and iron not given 
by mouth until the gastric symptoms are relieved; if need be 
iron may here be given by rectum, in the form of the tincture 
of iron in starch enema. Occasionally cases of chlorosis suffer 
from severe gastralgia, which is markedly aggravated by the ad- 
ministration of iron; in such cases the hyperesthesia of the 
stomach should first be treated by the use of hot applications 
to the epigastrium, a milk diet, small doses of cocaine, as de- 
scribed elsewhere, or of silver nitrate (see index) ; or menthol, 
preferably combined with some alkali may be given in small doses 
(0.05 to 0.1 gm.) a day. A very good formula that seems to be 
well tolerated by sensitive stomachs is the following: 



R 



Ferri lactic. 

Rad. rhei, a a 

Extr. gent. qs. 

F. pill No. 100. 

S. Two to three pills thrice daily. 



5.0 



DISEASES OF THE BLOOD 171 

The use of iron waters is occasionally beneficial, especially Iron waters 
if the waters can be taken at the resort where the iron source 
is. The use of bottled iron waters, however, is, as a rale, use- 
less, because most natural iron waters contain the iron in solu- 
tion as a carbonate; when they are bottled the carbonic acid 
evaporates in great part and the iron precipitates out, so that 
the water itself contains practically no iron. This objection 
does not, however, apply to waters containing the sulphate or 
chloride of iron. 

Arsenic is less important in chlorosis than in other forms of Arsenic 
anemia. As it possesses a general tonic effect in small doses, its 
administration, however, can do no harm. It is best given in the 
form of Fowler's solution, beginning with small doses, e. g\, 
three to five drops in plenty of water three times a day and in- 
increasing the dose a drop a day until fifteen to twenty drops are 
being taken in the twenty-four hours; and then the dose should 
gradually be reduced, and, if necessary, a second course of this 
kind instituted. The existence of dyspeptic symptoms, however, 
is a distinct contra-indication to the use of arsenic in chlorosis. 

If the stomach is exceedingly sensitive, then arsenic is best 
administered subcutaneously, either in the form of Fowler's solu- 
tion diluted with three parts of water, of which 0.5 cc. are admin- 
istered every other day in the beginning and later every day. I 
have used atoxyl (see index) in ten per cent solution at first 
0.1 cc. and then in gradually increasing doses two or three times 
a week. Finally Ehrlich's preparation, arsacetin, is useful. It is 
less liable to decompose in solution and is free from disagreeable 
after symptoms. It is employed in the form of a fifteen per cent, 
solution, of which first 0.1, and then gradually increasing doses, 
should be administered daily. Occasionally a combination of ar- 
senic and iron, especially ferrum cacodylicum, may be administered 
in the dose of 1 cc. of a five per cent, solution daily. 

Lecithin has been used extensively in diseases of the blood. The Lecithin 
consensus of opinion seems to be that it exercises an effect upon the 
red blood corpuscles, causing an increase in their number and an 
increase in the hemoglobin, even in cases in which iron is ineffi- 
cient. Particularly favorable results are reported in chlorosis and 
secondary anemia, while in pernicious anemia no effect is observ- 
able. Many patients seem to increase in weight and to feel gently 
stimulated after a prolonged course of lecithin. It is best adminis- 
tered in pill form in the dosage of 1 to 2 grams two or three times 
a day. 

A newer lecithin preparation is neocithin that in addition to Neocithin 
lecithin contains ferruginous albumins, nuclein, sugar of milk, and 
cocoa. It has been used with much success in anemia, chlorosis, 



172 



DISEASES OE THE BLOOD 



neurasthenic conditions and during convalescence. It seems to 
exercise an influence upon the hemoglobin and the red blood cor- 
puscles, leading to an increase of both. It also seems to stimulate 
the appetite. The proper dose is two teaspoonfuls two or three 
times a day. administered in soda, milk, coffee or water. 

Dyspnea Symptomatic treatment of the cardio-vascular signs is rarely 

necessary, because they improve under rest and iron. The 

Palpitation dyspnea, therefore, and the palpitation that these patients complain 

of rarely call for special treatment. 

Bleeding A word of warning may be uttered in regard to the dangers 

of bleeding cases of chlorosis, a practice that has recently be- 
come popular again. The plethora is removed only for a short 
time by venesection; and in chlorosis especially, owing to the 
disturbed vaso-motor tone, a reactive outpouring of fluid into 
the blood soon occurs, so that the purpose of the bleeding is im- 
mediately counteracted or even over-balanced and nothing is 
gained. The one possible benefit that could accrue from bleeding 
must be attributed to the profuse perspiration that usually fol- 
lows venesection in chlorosis; but this beneficial stimulation of 

Sweating the lymph flow, and the loss of fluid through the sweat glands, 

can be produced much more easily by hot baths or hot air. 
Sweating, therefore, is often useful in chlorosis for it promotes 
concentration of the blood and hence better nutrition because each 
unit volume of blood contains more hemoglobin. In chlo- 
rosis particular care, however, must be exercised to prevent cere- 
bral anemia from sweating by heat, so that this treatment should 
never be instituted with the patient sitting up, and cold applica- 
tions should always be made to the head while the patient is be- 
ing sweated. 



LEUKEMIA. 



Leukemia and 

pernicious 

anemia 



Leukanemia 

Causal treat- 
ment 



Although the blood picture of leukemia differs altogether from 
that of pernicious anemia, the two classes of blood disorder, 
nevertheless, must be considered as pathogenetically related; for 
in both instances we have some noxious agency, presumably 
toxic in character, affecting the blood-forming organs and chiefly 
the bone-marrow. Occasionally individual cases are seen in 
which both the red and the white cells are simultaneously affect- 
ed, so that a disease is produced that occupies an intermediary 
position on the border line between pernicious anemia and leuke- 
mia. This has been called leukanemia. 

The causal treatment of leukemia is therefore the same as 
that of pernicious anemia, in both cases unfortunately equally 



DISEASES OF THE BLOOD 173 

unsatisfactory, because in neither case do we know where to 
concentrate our attack. In leukemia, in fact, we know even less 
what indicatio causalis to meet than in pernicious anemia. Nev- 
ertheless, every effort should be put forward to look for a pos- 
sible cause and particular attention should be bestowed above all 
upon bowel antisepsis and the removal of intestinal parasites. Free 
evacuation of the bowel contents, and treatment directed towards 
any systemic disorder (syphilis) that may be present and that 
might even remotely be accused of causing the leukemic blood 
picture, should be energetically instituted. 

The treatment, causal and symptomatic, of the different forms Splenic, > 
of leukemia is the same. The old pathogenetic differences be- myelogenous 
tween splenic, lymphatic and myelogenous leukemia that have leukemia 
been formulated have only an anatomic interest and can 
no longer be recognized as useful for clinical differentiation. The 
preponderance, in individual cases, of lymphatic or of splenic 
swellings is nowadays considered to be of subordinate importance; 
for hyperplasia of the spleen or lymph glands, or of both, 
occurs both with and without lymphocytosis. On the other hand, 
leukemia may occur with myeloid degeneration of the bone-marrow 
and no splenic or lymphatic swellings. We can conclude from this 
that in leukemia, as well as in pernicious anemia, the inflammation 
of the bone-marrow is after all the most important and presumably 
the determining factor. For clinical purposes it is simpler and 
more exact therefore merely to speak of a lymphocytic and 
a leucocytic leukemia, indicating in this way that in the for- Lymphocytic 
mer case the lymphocytes predominate in the blood, in the latter i^k e mJa° Cy 1C 
the leucocytes, i. e., neutrophile, eosinophile, polynuclear and mast 
cells. 

Leukemia, as far as we know, is presumably never cured, Limitations of 
but life can be prolonged, and long remissions with improve- leukemia 
ment of the blood picture and great symptomatic relief can be 
brought about by judicious treatment. The use of any remedy in 
leukemia should be carefully instituted. Whenever any drug is 
given the effect should always be carefully watched, for 
leukemic patients, possibly owing to the perversion of their leu- 
cocytic (antitoxic) function seem to be particularly susceptible 
to drug intoxications; moreover, they frequently suffer from dys- Care in giving 
pepsia and diarrhea, all elements that render them especially kenfic patients 
liable to drug poisoning and that should be included in the cal- 
culation both in prescribing drugs and in ordering the diet. 

The remedy that seems of the greatest value in leukemia is Arsenic 
arsenic. It should be given as in pernicious anemia. Provided 
the gastric functions are normal it may, however, with care 
be given in somewhat larger doses at first in leukemia than in 



174 



DISEASES OF THE BLOOD 



Dose and ad- 
ministration 



Sodium arsen- 
iate 

Sodium caco- 
dylate 

Injection of 
arsenic 



Quinine 

Phosphorus 

Iodine 



Extracts of 
spleen 

Lymph glands 
Bone marrow 



Oxygen 



Tuberculin 



anemia. It is usually safe to begin with three times fifteen drops 
of Fowler's solution a day during the first week, giving three times 
twenty drops during the second week, three times twenty-five drops 
during the third week and, if no toxic symptoms appear, three times 
thirty drops during the fourth week. This dose should be con- 
tinued for some time until favorable changes appear in 
the blood picture, and it may then be gradually reduced 
by stages. Several courses of arsenic should be given. It is 
occasionally good practice to change the preparation of arsenic and 
to alternate with the use of Fowler's solution, sodium arseniate 
and sodium cacodylate. 

The injection of arsenic into the lymph glands or into the 
spleen is to be condemned in leukemia. The effects produced 
by this treatment have never been favorable and, per contra, 
much damage has been done. Subcutaneous inflammation and 
necrosis; infarction and other mechanical injury to the lymph 
glands and to' the spleen; rupture of the spleen; severe hem- 
orrhages ; have all been reported. 

Quinine has also been very warmly recommended in the treat- 
ment of leukemia. It may be given as the muriate of qui- 
nine, in doses of five to fifteen grains (0.3 to 1.0 gm.) three 
times a day, preferably in combination with arsenic or iron. 
Phosphorus, too, is occasionally of value in leukemia. A very 
useful prescription is the syrup of iron phosphate with quinine 
and strychnia. It may be given in half or teaspoonful doses, 
three or four times a day. Iodine and the iodides are no longer 
used in leukemia, although at one time they were considered to 
be efficacious. 

Extract of spleen, lymph glands and bone-marrow are ex- 
tensively used in leukemia. I have never been able to convince 
myself of their efficacy; nevertheless, there can be no harm in 
employing them, as some reliable authorities claim to have seen 
benefits accruing from their administration. All conclusions 
however, in regard to the efficacy of these, or, for that matter, of 
any other remedy in leukemia must be very conservatively inter- 
preted, because the disease has a natural tendency to spontaneous 
remissions. 

The inhalation of oxygen occasionally affords symptomatic 
relief, especially in cases with severe dyspnea and cardiac weak- 
ness. At least 100 to 150 liters of the gas should be given during 
twenty-four hours, if any good effects are to be expected. 

The fact that leukemia occasionally seems to improve if the 
subjects develop some intercurrent infectious disease, chiefly 
erysipelas and tuberculosis, has been utilized therapeutically. 
Tuberculin and erysipelas antitoxin have been injected in some 



DISEASES OF THE BLOOD 175 

cases with good temporary results. This method, however, is ex- Erysipelas 
ceedingly precarious, and until further reliable data in regard to 
its efficiency shall be forthcoming it is best to suspend judgment 
in regard to its use. 

Local treatment is to be absolutely condemned. At one time Injections of 
it was fashionable to inject arsenic or ergot into the lymph glands j™ p h glands 
or the spleen, to perform galvano-puncture or even to practise Ga'lvano- 
extirpation of large lymph glands or of the spleen. Lymph gland puncture 
excision has never produced any good results in leukemia. The 
practice, moreover, is irrational, because, as stated above, the pri- 
mary affection must not be sought for in the lymph glands, but 
rather in the bone-marrow. All the cases in which the spleen was 
excised died very promptly, probably sooner than they would have 
died without splenectomy, so that even this operation, however Splenectomy 
useful it may appear for the purpose of relieving great intra- 
abdominal pressure when the spleen attains enormous dimensions, 
must be considered unjustifiable. 

The diet in leukemia should take into consideration the state Diet 
of the digestive apparatus, but, broadly speaking, should be 
abundant and highly nutritious, and should consist largely of 
nitrogenous material; and every effort should be put forward 
to maintain adequate nutrition, in order that the patient may 
possess the greatest resisting powers to combat the inroads of the 
disease. 

Symptomatic treatment of the dyspepsias, of the hemorrhages, Symptomatic 
of cardiac weakness, is spoken of in the Sections on Diseases complications 
of the Stomach and Intestine, the Hemorrhagic Diathesis and Dis- 
eases of the Heart. 

For the profuse sweats that frequently torture leukemic pa- Treatment of 
tients alum applied to the surfaces of the body in one per cent. f^enSa "* 
solution; or camphoric acid, given by mouth, in doses of from 
fifteen to thirty grains (1 to 2 gm.) in capsule, or atropin one- 
two-hundred-and-flftieth grain (% m g-) repeated, by mouth and 
hypodermically ; or the extract of belladonna, in quarter to one 
grain doses, or finally, agaricine, in doses of one-twelfth to one 
grain (5 to 60 mg.) in pills, repeated, may be used. 

The effect of the Eoentgen rays on the blood has been ex- Roentgen 
haustively studied of recent years. Their action upon normal blood, rays 
such as one finds it in pseudo-leukemia consists in a reduction of 
the leucocytes, especially of the mononuclear variety. In leukemic 
blood there is also nearly always a reduction in the number of leu- 
cocytes, sometimes at once, more frequently, however, after a period 
of latency. In myelogenic forms of leukemia the myelocytes are 
the ones to become reduced first. A certain prognostic significance 
can be attached to the decrease in the number of myelocytes, in so 



176 



DISEASES OF THE BLOOD 



far as in cases that run a more favorable course the reduction of the 
myelocytes appears to be much greater than in those that run an 
unfavorable course. The mast-cells seem to be particularly resistent 
to the action of the X-rays. In lymphemias the lymphocytes be- 
come reduced but not to the same degree as the myelocytes in leu- 
kemia, so that the leukemic blood picture seems to remain more per- 
sistent. No regular effect can be seen upon the red blood corpuscles. 
The best effects are obtained by irradiation of the spleen and lymph 
glands rather than of the bones. 

PSEUDO-LEUKEMIA. 



Nomenclature 
and definition 



Hodgkin's 
disease 

Splenic 
anemia 

Band's 
disease 

Pseudo-leu- 
kemia spleno- 
lymphatica 

Recurrent 
glandular 
fever 

Tuberculous 
adenitis 

Scrofula 

Sarcomatosis 
of lymph 
glands 



The prefix "pseudo" placed before the name of a disease is 
intended to designate a special syndrome that differs from the 
disease it simulates; pseudo means false. There cannot, how- 
ever, be a false leukemia but there can be a false name, and 
pseudo-leukemia is in fact merely a designation for a variety of 
diseases that resemble leukemia in some of their manifestations 
but are not leukemia. 

Inasmuch as in leukemia swelling of the lymph glands and 
the spleen is common, many different disorders that lead to lym- 
phatic and splenic enlargements without the characteristic blood 
picture of leukemia, have been grouped under the name of pseudo- 
leukemia. In some of these disorders the lymph swellings pre- 
dominate ; in others the splenic tumor. All show the blood picture 
of a simple anemia, occasionally also a lymphocytosis. Pseudo- 
leukemia rarely develops into true leukemia, then namely, as shown 
in the previous sections, when the bone-marrow becomes involved 
in the disease process. 

If the lymph swellings predominate we speak of pseudo-leu- 
kemia lymphatica (Hodgkin's disease) ; if the splenic tumor 
is particularly developed of pseudo-leukemia splenica, or splenic 
anemia; when it appears combined with hepatic cirrhosis and 
simple anemia, of Banti's disease. In all cases both the spleen 
and the lymph glands are probably involved to some extent; if 
they are both equally involved we speak of pseudo-leukemia spleno- 
lymphatica. 

Again, the lymphatic swellings may be accompanied by a 
remittent or intermittent type of fever, then we have recurrent 
glandular fever; this form is presumably a tuberculous adenitis, 
and as a matter of fact many cases of multiple tuberculous lymph- 
gland swellings, as well as scrofula, are often included under the 
head of pseudo-leukemia. The same applies to multiple sarco- 
matosis of the lymph glands, that often cannot during life be dis- 
tinguished from simple lymphadenomata. 



DISEASES OF THE BLOOD 177 

It will be seen, therefore, that the term pseudo-leukemia covers 
a multitude of different clinical entities, many of them of 
unknown etiology. Some of the cases seem to develop on the basis Etiology 
of tuberculosis or malaria, others after diseases of the tonsils and 
pharynx, after measles, whooping cough and especially influenza. 
Given an inherited or acquired syphilis and vulnerability of lym- 
phoid tissue, then a variety of noxious agencies seem capable of pro- 
ducing general lymphadenitis and splenitis. What factors deter- 
mine this disposition and what noxious agencies become operative 
to cause the swellings, whether they are infectious or toxic, endo- 
genous or exogenous, we do not always know. 

It is clear, therefore, that effective causal treatment and prophy- Causal and 
laxis of the various forms of pseudo-leukemia are, in the obscurity treatmenMm- 
of our present knowledge, impossible. possible 

Symptomatic treatment is, however, often efficacious in re- Symptomatic 
ducing the glandular swellings and the splenic tumor, especially treatment 
early in the disease, and in correcting the anemia that usually 
complicates this disorder. With the reduction of the tumors most 
of the pressure symptoms produced by them promptly yield so 
that the latter rarely call for special treatment. 

The chief remedy, again, is arsenic, employed as described Arsenic 
under Leukemia, i. e., either in the form of Fowler's solution, 
or as arsenious acid, or in the form of the Asiatic pill. All 
these arsenic preparations, if given by mouth, should be admin- 
istered after eating. In pseudo-leukemia sodium cacodylate (so- 
dium dimethyl arseniate) is also a useful remedy. It contains 
nearly two-thirds parts of arsenious acid and seems to be less irri- Sodium 
tating to the stomach than Fowler's solution or the ordinary arsen- cac0 y a e 
iate of soda. It should be administered in pill form, each pill 
containing from one-sixth to one grain (0.01 to 0.06 gm.). From 
one to six pills a day may be safely administered, or a watery 
solution may be employed in the strength of one to fifteen, from 
five to twenty-five drops a day being given of the latter. After the 
use of cacodylate of sodium the patients very soon develop a char- 
acteristic odor of garlic on the breath. 

Whereas, in leukemia, the subcutaneous or intra-parenchy- Intra-paren- 

matous administration of arsenic in any of its forms is to be con- w^ns 01 ^ * 

demned as useless, irrational and dangerous, in pseudo-leukemia arsenic 

it occasionally acts beneficially. One may either give Fowler's 

solution or sodium arseniate. If Fowler's solution is used, either Technique 

Fowler s solu- 
for injection into lymph glands or into the muscle tissue, pref- tion 

erably of the gluteal and anterior abdominal region, it is best to 
administer it diluted in the proportion of one to three with water 
to which one-half per cent, of carbolic acid is added as an anti- 
septic. Of this solution about % cc. should be injected at a time 



178 



DISEASES OF THE BLOOD 



Solution of 
sodium arsen- 
iate 



Quinine-phos- 
phorus 

Iodide^ of 
potash 



Local appli- 
cations 

Sapo kalinus 
Iodoform 



in the beginning, and the dose gradually increased later on if 
no untoward symptoms develop. Better than Fowler's solution 
for injection is sodium arseniate. This is prepared as follows: 
1.0 gm. of arsenious acid is boiled with 5 cc. of normal sodium 
hydrate solution until a clear solution is obtained, and 600 cc. 
of distilled water are then added. In using this solution for in- 
jection a Pravaz syringe is filled one-half with water and 
one-half with sodium arseniate solution and about 1 cc. of 
this mixture is injected into the enlarged lymph glands. Still an- 
other useful preparation for hypodermic use is a 10 per cent, 
solution of sodium cacodylate of which half a Pravaz's syringe 
full is injected at a time. Painless arsenic injection is described 
on page 177. 

The indications for the use of quinine and phosphorus are 
the same as in leukemia. These remedies act as general tonics 
and occasionally do some good. Iodide of potash also has a 
place in the treatment of pseudo-leukemia; it should be given 
in the form of the saturated solution, in gradually increasing 
doses. In general tuberculous adenitis, however, I consider this 
drug dangerous ; one should, therefore, always be quite sure of one's 
diagnosis before employing it. 

For local application the best remedy is green soap (sapo ka- 
linus viridis) or sapo kalinus. Of this about a teaspoonful is 
daily rubbed into the skin over the affected glands. Occasionally 
the addition of iodoform to this soap is of use; for the alkali in the 
soap loosens the epidermis and permits the free entrance 
of iodoform into the tissues surrounding the affected gland. A 
very good mixture is : 



E 



Iodoform, 

Sapo kalinus, 

Vaselin, 

M. S. For local use. 



5 gm. 
aa 20 gm. 



Iron and ar- 
senic for the 
anemia 



In view of the simple anemia that is generally present, iron, as 
described in the part on The Anemias, is indicated. One can 
conveniently combine iron and arsenic by giving the cacodylate 
of iron, thus : 



K 



Cacodylate of iron, 1.0 gm. 

Cinnamon water, 25.0 cc. 

M. S. Fifteen to fifty drops three times a day, 
after meals. 



DISEASES OF THE BLOOD 179 

In case all of these medicinal measures, combined with, proper Indications 
feeding and ideal hygienic conditions, fail to cause the dis- tirpation 
appearance of the glandular swellings, and especially if cer- 
tain glands, by mechanically compressing important nerve 
branches or blood vessels, produce disagreeable secondary symp- 
toms, then extirpation of the glands becomes necessary. Some 
clinicians go so far as to claim that the excision of a few of the 
enlarged glands exercises a beneficial effect upon the whole dis- 
ease process. Others, again, claim that excision per contra oc- 
casionally produces an aggravation of symptoms and ac- 
celerated growth of the remaining glands. For the purpose, there- 
fore, of influencing the disease process, gland extirpation is prob- 
ably a doubtful, possibly a precarious, procedure, and the only 
real indication for performing this operation is the relief of pres- 
sure symptoms. 

In cases of splenic anemia, i. e., pseudo-leukemia in which the Treatment of 
spleen enlargement predominates over the lymphatic swellings, anemia 
arsenic, iron and the other medicines recommended above are 
also indicated. Injections of arsenic, however, into the spleen 
itself are always a dangerous procedure and have so far never 
produced results sufficiently favorable to warrant their recom- 
mendation. On the contrary, disagreeable and dangerous results 
have often followed this practice so that it is to be condemned as 
useless and unwarranted. 

The application of green soap, or of any other remedies, over 
the splenic region, excepting as counter-irritants to relieve pain, is 
useless. Electrization of the spleen, which has also been recom- 
mended, is altogether without effect. Cold continuously applied Cold to the 
to the splenic region occasionally produces at least symptomatic Sp 
relief and has been known to reduce the splenic swellings. The 
ice-bag intermittently applied is probably the best and simplest 
method of producing this result. 

A variety of remedies has, at different times, been recom- Quinine 
mended for reducing the splenic tumor, chief among them being Eucalyptus 
quinine and eucalyptus. These remedies, however, presumably 
exercise their good effect only in cases of large malarial spleen, 
and they should therefore only be used if the existence of malaria 
can be determined by examination of the blood; otherwise they 
are useless. 

Excision of the spleen has been frequently performed, and Splenectomy 
in some cases this operation has been followed by very favorable 
results, especially if splenectomy was performed relatively early 
in the disease. The main indications for splenectomy in advanced 
cases are pressure symptoms due to the often enormously en- 
larged organ ; if many lymph glands are involved at the same time 



180 



DISEASES OF THE BLOOD 



the results are far less favorable. The operation, of course, is not 
without dangers, especially if adhesions have formed in the region 
of the spleen. The existence of a cirrhosis of the liver is always 
a contra-indication to splenectomy; consequently in Banti's dis- 
ease this operation should not be performed. 



THE HEMORRHAGIC DIATHESIS. 

Classification There are a number of diseases of obscure origin that are 

Scurvy characterized by the occurrence of hemorrhages in various or- 

Hemophilia gans. The chief representatives of this group are scurvy, hemo- 

Purpura philia, and purpura. This classification is more or less arbitrary 

and the three disorders are closely related and occasion- 
ally merge into one another. Hemophilia, in the overwhelm- 
ing majority of cases is due to a transmitted hereditary taint and 
is a permanent condition, whereas scurvy and purpura 
rheumatica are acquired, the former often occurring endemic- 
ally, usually as the result of malnutrition with severe 
general disturbances; the latter always occurring sporadically, 
generally without severe systemic disturbances and rarely de- 
pendent upon definite external conditions. Even in scurvy and 
purpura, however, one is almost forced to the conclusion that 
a congenital predisposition to hemorrhages exists by the 
occasional appearance of scurvy or purpura in subjects 
who are healthy and in whom none of the predisposing or de- 
termining factors that are usually incriminated with producing 
these diseases are operative. The diseases grouped under the 
name of the hemorrhagic diathesis, especially, nowadays, scurvy, 
are fortunately very rare, so that their treatment is rela- 
tively of subordinate importance and may hence be discussed very 
briefly. 

SCURVY. 



Causal treat- 
ment 



Diet 



A number of theories in regard to the causes of scurvy ex- 
ist. There seems to be no doubt that food factors play an 
important role in its production. The absence of potassium salts, 
the excessive ingestion of salted foods, the lack of sufficient vege- 
tables and fruits, the lack of fat in the diet have all been ac- 
cused of producing the disease. At all events, in the practical 
treatment of the disease fresh vegetables containing po- 
tassium salts, viz., chiefly potatoes, cabbage, spinach, watercress, 
carrots, turnips, onions, artichokes, asparagus, oranges, and in 
addition milk, fresh meat, containing the blood, and meat 



DISEASES OF THE BLOOD 181 

extracts should above all things be immediately supplied. As a 
rule a scorbutic patient if placed at rest and fed on a diet of Rest 
this character will recover without further medicamentous inter- 
ference. 

As a prophylactic measure the use of lemon or orange juice Prophylaxis 
has been recommended, especially in children who are fed upon 
artificial foods lacking so-called anti-scorbutic elements, and 
in individuals, like sailors or arctic explorers, who are forced 
to live for long periods of time upon a diet consisting largely 
of preserved foods. In the English navy, for instance, it is a com- English navy 
pulsory rule that the sailors be given every day a lemonade con- regu 
sisting of 14 gm. of lemon juice, 4,29 gm. of sugar and 112 gm. of 
water, at dinner. 

The establishment of ideal hygienic conditions is also of great Hygiene 
importance. There seems to be no doubt that lack of light and 
fresh air, exposure to cold and dampness and lack of proper ex- 
ercise all contribute towards the outbreak of scurvy,, especially 
when many subjects are massed together in one dwelling for 
long periods of time. 

Of remedies that have been recommended herba cochlearias Horseradish 
(Horse-radish) was for a long time the most popular one. Aro- 
matic tonics, tannic acid, quinine and many other remedies have Aromatic 
been recommended, but it is generally unnecessary to give these tonics 
medicines excepting to stimulate the appetite, or as general tonics. 
Yeast, too, is advised in doses of 200 to 300 gm. daily. tfeast 

Particular attention must be paid to the laceration of the Treatment of 
gums, for this is one of the most distressing symptoms of the e 
disease. Here certain washes are necessary. Peroxide of hydro- 
gen may be applied directly to the gums, or a permanganate so- 
lution, 1 to 300, or a solution of silver nitrate, five grains to the 
ounce, or chlorate of potash solution, 1 to 50, or equal parts 
of the tincture of myrrh and catechu. In addition, the teeth should 
be carefully looked after and mechanical irregularities corrected. 
For the gum hemorrhages adrenalin, in 1 to 1000 solution, or 
cocaine (10 per cent, solution), or iron perchloride (concen- 
trated solution), or gelatine 10 per cent, (sterile!) are probably 
the best remedies. 

The same local treatment may be used in surface hemorrhages Surface hem- 
in other parts of the body. In bloody infiltration of muscles r 
the application of a hot mixture of vinegar, one part, and wa- 
ter, two parts, is frequently very grateful. Occasionally ice ap- 
plied to the bleeding area, or swallowed, in case of gastro- 
intestinal hemorrhage, is useful. The internal administration 
of styptic drugs like ergot, chloride of iron, etc., is useless. Oc- Styptics by 
casionally pressure bandages or tamponade become necessary to m u 



182 



DISEASES OF THE BLOOD 



stop hemorrhages. Surgical measures are always dangerous ow- 
ing to the hemorrhagic tendency that exists. Great care 
should also be exercised in the use of drastic purges or 
other drugs that stimulate violent peristaltic movement, for 
bowel bleeding may occasionally be produced by their admin- 
istration. 

HEMOPHILIA. 



Prophylaxis 



Marriage 



Individual 
prophylaxis 



Danger of 
minor oper- 
ations 



Care of the 
teeth 



Diet 



Medicamen- 
tous treatment 



In view of the hereditary character of this disease and the 
transmission of the disorder through the females of the family, 
immaterial whether they be hemophilic themselves or not, mar- 
riage of the women of "bleeder" families should always be for- 
bidden. Male members who are not hemophilic, however, may 
marry. If it is known that at one time in the family history of 
a hemophilic man hemophilic children were born from a hemophilic 
father, then the male members of such a family likewise should 
be advised against marriage. 

Individual prophylaxis in all members of a bleeder family 
is very important, especially during childhood and early ado- 
lescence. Thus all operative inroads, however slight they may be, 
should be avoided during childhood, as circumcision, the removal 
of moles, cutting of the frenum of the tongue, perforating the 
ears. Vaccination, however, seems to be without danger in hemo- 
philia, so that the children can be given the benefit of protective 
inoculation against smallpox. 

The care of the teeth is, of course, of the greatest importance 
and even slight defects should be treated with the object in view 
to prevent the necessity of tooth-extraction. Leeching, cupping 
and vesication should never be practised in children from hemo- 
philic families. 

The toys that they are permitted to play with should be of 
such a character that the children cannot injure themselves. Vio- 
lent gymnastic exercises, in fact, any pursuit that can lead even 
to slight surface abrasions or other bodily injury should be for- 
bidden. In choosing a calling some occupation should be se- 
lected that does not necessitate contact with machinery or the use 
of sharp tools. 

The diet in hemophilia should consist largely of vegetables and 
should be selected approximately on the same principles as the 
diet in scurvy (see index). Alcoholics, tea and coffee, condi- 
ments and spices should be reduced, in fact, nothing should be 
eaten that can irritate the cardio-vascular apparatus. 

A great number of remedies have been recommended for the 
cure of the hemophilic tendency, while but few of them have vindi- 



DISEASES OF THE BLOOD 183 

cated the claims advanced for them by the different clinicians who 
have advised their use. The laity have great faith in the use of 
large quantities of lemons or of other citrous fruits, and some Lemons 
clinicians report good results from the continued use of citrates. 
Mineral acids, too, deserve a trial, preferably sulphuric acid, Mineral acids 
either as acid sulph. dil., ten to thirty drops several times a day, 
or as acid sulph. aromat., five to fifteen drops. Magnesium and 
sodium sulphate are also spoken of favorably, the latter remedies Sulphates 
possibly acting beneficially from the sulphuric acid they con- 
tain, and through their effect upon the bowels; that is, by pro- 
moting watery evacuation and hence possibly greater concen- 
tration of the blood and also by counteracting the absorption of 
bowel poisons. 

Ergot, lead acetate, hydrastis, opiates, have all been rec- L , . 
ommended, but opinion seems to indicate that they are of no Hydrastis 
value in hemophilia. Opiates 

Hemorrhages, when they occur, must be treated chiefly me- Treatment of 
chanically and according to surgical principles, i. e., the bleed- u™ 11 !?? • ff s 
ing part must be elevated, compression applied above the bleed- means 
ing area and occasionally a ligature placed about the afferent 
artery; thus a case of severe hemorrhage in a hemophilic follow- 
ing the extraction of a tooth is reported in which the common 
carotid had to be ligated before the bleeding stopped. 

The subcutaneous injection of gelatine may also be tried. A Subcutaneous 
2 to 3 per cent, neutralized solution of sterile gelatine in physio- gelatine 
logical solution should be heated to body temperature and from 
5 to 200 cc. injected under the skin (technique, see Aneurism of 
the Aorta). This occasionally stops the bleeding. Calcium chlo- Calcium 
ride, to judge from the case reports that have been published, is of 
no value. 

Surface hemorrhages should be treated as described under Surface hem- 
Scurvy. Joint hemorrhages and hemorrhages into the various bleeding into 
serous cavities of the body (pericardium, pleura, peritoneal cavities 
cavity), epistaxis, etc., call for special treatment, the details of 
which are described in their appropriate places. 



PURPURA. 

Various forms of purpura have been distinguished under the Nomenclature 
names of purpura simplex, purpura hemorrhagica, purpura rheu- 
matica, syn. peliosis rheumatica or Schoenlein's disease, and mor- 
bus maculosus of Werlhoff. All forms of purpura are closely 
related and the clinical differences are very artificially constructed. 
At the bottom of all these disorders is a hemorrhagic dia- 



184 



DISEASES OF THE BLOOD 



Causes 



Symptomatic 
multiple hem- 
orrhages due 
to sepsis 



Causal treat- 
ment of the 
above 

Symptomatic 
treatment of 
purpura 



Diet 



thesis, i. e., generally a pale, tender, vulnerable skin with a tend- 
ency to bleeding, and usually an anemic condition of the blood. 
Such individuals are particularly susceptible to tempera- 
ture changes and hence to rheumatoid disorders, so that the sim- 
ultaneous appearance of hemorrhages, joint exudates and mus- 
cle pains is not to be wondered at (hence the name "purpura rheu- 
matica"). 

The cause of these disorders is not definitely known. Some 
cases seem to be due to an infectious agent (bacillus purpura, 
Letzerich) ; in others a ferment intoxication is probably causing 
chemical blood changes; in still other, more chronic forms, the 
blood vessel walls seem to be particularly affected (endarteritis 
with hyaline or fatty degeneration of the muscular layers and 
fragility of the walls). Some cases seem to accompany chronic 
nephritis, especially with pronounced cardio-vascular manifesta- 
tions; here again a weakening of the vessel walls engrafted upon 
the hemorrhagic diathesis may be incriminated. 

From a therapeutic standpoint it is very important to dis- 
tinguish true purpura from symptomatic multiple hemorrhages 
due to sepsis or accompanying a variety of infections or intox- 
ications (small pox, petechial typhus, cholera, plague, yellow fever, 
anthrax, acute yellow liver atrophy, phosphorus poisoning, icterus 
gravis, snake poisoning, pernicious anemia, etc.). In the septic 
form of multiple cutaneous hemorrhages one frequently finds ul- 
cerative endocarditis with secondary multiple septic emboli in the 
capillaries of the skin and other portions of the body; there is 
also a so-called purpura gonorrheica closely related to the above. 
None of these forms constitute true purpura, although this name 
is often falsely given them. 

The treatment here must be directed principally against the 
underlying disorder of which the hemorrhages are merely an un- 
important, and by no means a constant, manifestation. 

The treatment of true purpura, in view of our ignorance in 
regard to its etiology, must unfortunately be largely symptomatic. 
During the periods of remission that occur, the patient should, 
above all things, be protected from catching cold; hence life in a 
warm climate is to be recommended whenever feasible. Hygienic 
conditions should be perfect, and above all nervous or emotional 
shock or over-strain should be strenuously avoided, for in some 
cases sudden fright or anger have been known to precipitate attacks. 

The treatment of the attack always calls for rest in bed. The 
diet should be bland and should be similar to that described in 
the other manifestations of the hemorrhagic diathesis. Coffee, tea, 
alcoholic liquors, spices, condiments and all other articles that can 
excite the vasomotors should be omitted. For a time, especially 



DISEASES OF THE BLOOD 185 

in the beginning, milk and cream with some bread or cereal and a 
little lemonade or orangeade should constitute the food. 

Particular care should be devoted to the regulation of the bowel Regulation of 
function, and the stools should be carefully examined for the ap- e owe s 
pearance of blood, denoting intestinal hemorrhage, which would Intestinal 
require special treatment (see index). Intestinal parasites, emorr age 
that have been accused of some role in the production of the 
disease, should always be looked for and should be removed if 
present, as described in the Chapter on Intestinal Diseases. There 
is no specific remedy but, according to most authorities, sulphuric Sulphuric acid 
acid has been declared a very useful drug. It may be given 
as acid, sulph. dil. in ten to thirty drop doses, or as acid, sulph. 
aromat. in five to fifteen drop doses, in water, several times 
a day. Fowler's solution is always indicated and should be giv- Fowler's solu- 
en as described under Pernicious Anemia. Ergot, in the form Ergot 
of the fluid extract, in the dose of ten to thirty drops, repeated, 
is warmly recommended, especially in children. Oleum terebin- OL terebin- 
thinse rect. (dose ten to fifteen drops) is endorsed by no less an 
authority than Litten. Chloride of iron in doses of one Chloride of 
to five drops a day, in milk, or the extract of hydrastis, in doses of jjvdraatis 
twenty to thirty drops every three or four hours, are also spoken 
of favorably. 

In all cases of purpura with marked rheumatic manifestations Anti-rheu- 
(peliosis rheumatica) an anti-rheumatic treatment should be in- men t 
stituted, as mentioned in the part on Rheumatism. It will gen- 
erally be found that the pain in the muscles and ten- 
don sheaths as well as in the joints stops as soon as the 
hemorrhages into the joints occur. The special treatment of the Hemarthrosis 
hemorrhagic joints (hemarthrosis), of blood extravasations into Serous hem- 
the serous sacs, of nose bleed, etc., that occasionally occur in this, 
as in all the other manifestations of the hemorrhagic dia- 
thesis, is discussed in full in the sections on the different 
organs affected. 



CHAPTER III. 

DISEASES OF METABOLISM, 



THE LAWS OF NUTRITION. 

That we may understand the pathology of a disease, and 
that we may intelligently treat it, it is necessary to understand 
the function or functions a perversion of which it represents. In 
the case of the diseases to be discussed in this chapter it is there- 
fore essential to appreciate the fundamental principles that under- 
lie metabolism before attempting to treat its disorders. The 
manifold facts that constitute the sum total of our knowledge of 
this subject cannot be discussed in full within the comparatively 
narrow limits of this book. I will content myself, therefore, with 
describing those elements merely that have a direct practical bear- 
ing upon treatment. 

The food of man consists of organic and inorganic constit- 
uents. The former comprise water and a number of inorganic 
salts; the latter a variety of bodies containing carbon, oxygen, 
hydrogen, nitrogen and some phosphorus and sulphur, and classi- 
fied as proteids, carbohydrates and fats. The role of the inor- 
ganic and organic food elements differs; for, whereas the inor- 
ganic constituents pass through the body unchanged, the organic 
constituents undergo a number of fermentative and oxidative meta- 
morphoses so that they leave the body in the form of highly oxi- 
dized, inert, terminal products of which urea, water and carbon 
dioxide are the main representatives. 

In this process of oxidative destruction, which can be crudely 
likened to a combustion, and the finer intermediary mechanism 
of which need not be discussed in this place, a certain amount 
of energy is developed by each organic article of food. To meas- 
ure this amount of energy or its mechanical equivalent in heat or 
labor, the term calorie has been imported from the realm of phys- 
ics; a calorie being the amount of heat required to raise the tem- 
perature of one kilo* of water one degree Celsius. 



Introductory 

The laws of 
nutrition 



Composition of 
the food 



Inorganic and 
organic food 
elements 



Terminal 
products 



The develop- 
ment of 
energy 

Definition of 
calorie 



♦1 Kilo (kilogramme) = 2 lb. 3 oz. 2 dr. (avoirdupois) 
1 gramme = 15^ grains (15.432349 grs.). 



188 



DISEASES OP METABOLISM 



Caloric value 
of proteids, 
carbohydrates 
fats 



Daily caloric 
requirement 



Law of isody- 
namics 



Proteid mini- 
mum 



Average adult 
requirement 
expressed in 
grammes 
per kilo 



Caloric value 
of different 
articles of food 



It has been determined that each of the three food classes in 
process of metabolism (i. e., of assimilation^ splitting and oxida- 
tion) generates a definite number of calories, viz. : 

1 gramme* of proteid furnishes 4.1 calories 

1 gramme of carbohydrate furnishes 4.1 calories 

1 gramme of fat furnishes 9.3 calories 

It has further been determined that a normal adult requires 
from 30 to 35 calories per kilo of body weight a day in order to 
maintain nutritive equilibrium; i. e., assuming an average weight 
of 70 kilo, 70 X 30 = 35, or from 2,100 to 2,450 calories per 
diem. Theoretically this caloric requirement can be supplied 
vicariously by proteids, fats or carbohydrates; actually, however, 
this "law of isodynamics" is not valid; for the peculiarities of our 
digestive and assimilative functions, as well as the character of 
our intracellular metabolism, render it impossible for an indi- 
vidual to subsist on one food class alone. 

Above all a certain amount of proteid is essential. The abso- 
lute minimum lies somewhere between 40 and 80 grammes for 
the twenty-four hours' period. The average amount ingested is, 
however, much larger; the daily quantity of food containing from 
90 to 115 gm. of albumen (370 to 420 calories), 50 to 60 gms. of 
fat (465 to 560 calories), and 400 to 450 gms. of carbohydrate 
(1,640 to 1,850 calories) representing in round numbers a total 
of from 2,500 to 2,900 calories. The same expressed in grammes 
per kilo of body-weight signifies that a normal average adult re- 
quires 1.5 gm. of albumen^ 0.8 gm. of fat and 7.1 gm. of carbo- 
hydrate per diem per kilo. The amount of rest and exercise, and 
the sex (women requiring less total calories than men) and many 
other factors influence these figures somewhat. 

In order to perform dietetic calculations that, as will pres- 
ently be shown, are of great importance in the proper feeding of 
sufferers from metabolic disorders, it is necessary to know the 
caloric value of the different articles of food; to do this the per- 
centage of albumen, carbohydrate and fat each article contains 
must be known. The caloric value can then readily be determined 
by multiplying the grammes of albumen by 4.1, of carbohydrate 
by 4.1 and of fat by 9.3. The following table gives the approxi- 
mate albumen, carbohydrate and fat content of the most impor- 
tant common foods. 



*These figures hold good only for pure albumen, carbohydrate 
and fat. The actual amount of caloric value that is placed at the dis- 
posal of the organism by different foods depends, however, largely upon 
the physical properties of these foods, the amount lost in the feces; i. e., 
their digestibility, assimilability, and a variety of other factors peculiar 
to each individual, so that actually these figures must be modified to 
read: 

1 gramme of proteid furnishes 3.2 calories. 

1 gramme of carbohydrate furnishes 3.8 calories. 

1 gramme of fat furnishes 8.4 calories. 



DISEASES OF METABOLISM 



189 



TABLE I. 

TABLE GIVING PERCENTAGE OF ALBUMEN, FAT AND CARBOHYDRATE 
IN COMMON ARTICLES OF DIET. 

Animal Foods. Carbo- 

Albumen, Fat, hydrate, 
Kind of food. per cent. per cent, per cent, 

Veal, lean, raw 20.0 

Veal, fat, raw 19.0 

Beef, medium, raw 20.5 

Beef, fat, raw 21.0 

Beef, boiled 38.0 

Beef, roasted 32.0 



Meat broth 

Mutton, medium, fat, raw, 

Pork, raw, fat 

Pork, raw, lean 



.... 10.4 

.... 17.0 

.... 14.5 

.... 20.0 

Ham, lean, cured 24.0 

Chicken 21.0 

Duck 22.0 

Goose 16.0 

Pigeon 22.0 

Codfish 82.0 

Salmon (fresh) 21.0 

Trout 19.0 

Caviar 32.0 

Oysters 8.0 

Kidney 18.0 

Liver 19.5 

Tongue (boiled) 15.0 

Tongue (smoked) 24.5 

Bacon 9.5 

Suet 0.5 

Lard 0.5 

Frankfurter sausage 12.0 

Egg (with shell) 12.5 

White of egg 12.7 

Yolk of egg 16.0 

Milk 3.5 

Milk, skimmed 3.1 

Buttermilk 4.0 

Cream 3.6 

Butter 0.7 

Cheese (Swiss, American) 34.0 

Neufchatel cheese 19.0 

Camembert cheese 25.0 



Fat, 
per cent. 

1.5 

7.5 

1.5 

5.5 

9.15 

8.0 

0.6 

6.0 
37.5 

7.0 

8.0 

2.0 

3.0 
45.1 

1.0 

0.5 
12.5 

2.0 
15.5 

1.5 

5.0 

4.5 
17.5 
31.5 
76.0 
98.0 
99.0 
40.0 
12.6 

0.25 
32.0 

4.0 

0.7 

0.9 
25.0 
84.0 
11.0 
41.0 
30.5 



2.0 

2.0 

0.76 



2.0 

2.6 

0.15 

3.28 

0.5 



2.25 

0.5 

0.7 

0.1 

4.9 

4.8 

3.7 

3.5 

0.6 

3.5 

1.0 

1.5 



190 



DISEASES OF METABOLISM 



Vegetable Foods. 

Carbo- 

Albumen, Fat, hydrate, 

per cent. per cent, per cent. 

Wheat flour 10.0 1.0 72.0 

Oatmeal 13.5 6.0 67.0 

Wheat bread 7.0 0.5 52.0 

Eye bread 6.0 0.5 47.0 

Zwieback 13.0 3.0 80.0 

Marconi and noodles 9.0 0.5 77.0 

Eice 9.0 1.0 78.5 

Potato 2.0 0.2 20.5 

Carrots 1.0 0.2 8.0 

Peas (green) 6.0 0.5 11.0 

Cabbage 2,5 0.5 6.5 

Cauliflower 2.5 0.3 4.5 

Sauerkraut 1.0 0.2 4.5 

Spinach 3.0 0.5 5.0 

Asparagus 2.5 0.4 2.5 

Dried peas 23.0 2.0 52.5 

Beans 24.5 2.0 52.0 

Eadishes 1.2 0.1 3.7 

Lettuce 1.4 0.3 2.2 

Cucumber 1.0 0.09 2.2 

Sugar 0.5 96.5 

Olive oil 95.0 

Fresh fruit 0.5 10.0 

Mushrooms 2.5 0.1 4.8 

Beverages. _, , 

Alcohol, Albumen, Fat, bohyrate, 

per cent.* per cent. per cent. per cent. 

Beer 4.0 4.3 0.8 

White wine 10.0 1.6 

Claret 10.0 0.2 11.0 

Madeira 20.0 0.2 3.0 

Port 18.0 0.18 5.8 

Sherry 17.0 0.2 .... 5.0 

Champagne 11.0 0.2 12.0 

Brandy 70.0 

Coffee 0.16 0.5 1.4 

Tea 0.16 0.5 1.4 

Cocoa 14.0 47.0 18.5 

Chocolate 5.0 15.0 75.0 

*One gramme of alcohol has a caloric value of 7 



DISEASES OF METABOLISM 191 

This table is used as follows to calculate the caloric value of 
the diet that an individual is eating or to arrange a dietary in such 
a way that it will incorporate any desired quantity of calories. As- 
suming for instance that the individual is eating in the twenty- 
four hours the following articles of food, then the amount of al- 
bumen, fat and carbohydrate they contain can readily be gath- 
ered from the table as follows : 

Carbo- 
Articles. Albumen. Fat. hydrate. 

50 gm. of roast beef 16.0 4.0 .... 

100 gm. of chicken 21.0 2.0 2.0 

10 gm. of butter 8.4 .... 

20 gm. of potatoes 4.0 0.4 41.0 

100 gm. of oatmeal 13.5 6.0 67.0 

200 cc. of milk 7.0 8.0 10.0 

50 gm. of lettuce 0.6 0.2 1.7 

100 gm. of cauliflower 2.5 0.3 4.5 

200 gm. of white bread 14.0 1.0 104.0 

2 eggs at 50 gm 25.0 24.0 1.0 

100 gm. of rye bread 6.0 0.5 47.0 

100 gm. of fresh fruit 2.5 1.0 55.0 

50 gm. of sugar 0.1 .... 48.0 

50 cc. of maderia* ... 1.5 

Total 112.4 55.8 402.7 

The individual, then, is receiving 112.4 gm. of albumen, 55.8 
gm. of fat, 402.7 gm. of carbohydrates, and 10 gm. of alcohol. Ex- 
pressed in calories: 

Albumen, 144.4 X 4.1 = 460.84 cal. 

Fats, 55.8 X 9.3 = 518.94 cal. 

Carbohydrates, 402.7 X 4.1 = 1,651.07 cal. 

Alcohol, 10.0 X 7. = 70.00 cal. 



Total 2,700.8^ cal. 

On a mixed diet of this character the individual, therefore, is 
ingesting food of a total caloric value sufficient to more than ade- 
quately maintain nutrition; for, assuming the subject to weigh 
as much as 70 kilo, he would be receiving 2,700 — =— 70 = 38.5 cal- 
ories per kilo, distributed as follows: 

1.6 gm. of albumen 
0.8 gm. of fat 
5.74 gm. of carbohydrate 
per kilo of body weight. This, as shown above, would approximate 
very closely normal requirements. 
*20 per cent alcohol. 



192 



DISEASES OF METABOLISM 



The group of 
metabolic dis- 
eases 



Interrelation- 
ship of all 
metabolic dis- 
eases 



Inadequacy of 
causal treat- 
ment 



General thera- 
peutic indica- 
tions 



Loss of calor- 
ies in urinary 
sugar 



Among the diseases of metabolism are included diabetes, obes- 
ity, gout and the uric acid diathesis, osteomalacia, rachitis and, in a 
special sense, chronic rheumatism. In many other diseases per- 
versions of metabolism occur, but there the metabolic derangement 
is merely one more or less unimportant and, at all events, second- 
ary symptom of definite and known underlying causes. In the 
diseases of metabolism proper the metabolic derangement is the 
primary event and the determining factor in the production of the 
disease. 

All the diseases of this group, especially diabetes, obesity and 
the uric acid diathesis, are intimately related to one another patho- 
genetically, chemically and clinically. In one the perversion of 
the carbohydrate metabolism, in the other of the fat metabolism, 
in the third, of the proteid (nuclein) metabolism predominates, 
and each is characterized by an inability on the part of the organ- 
ism to destroy sugar or fat or albumen (nucleins) in a normal 
manner. In this way sugar, fat or nucleins and their congeners 
accumulate and the pictures of diabetes, obesity and gout are 
created. The metabolism of the proteids, fats and carbohydrates 
is, however, so intimately concatenated that, as a rule, we witness 
combinations of diabetes and obesity, of diabetes and gout, of gout 
and obesity, or of all three together. 

Causal treatment, in view of our ignorance, for the present, of 
the etiology of the diseases of metabolism, and also in view of the 
intangible hereditary element that is so important a factor in all 
functional weakness or perversion of the protoplasm at large, is 
not satisfactory, so that the main therapeutic indication is by 
dietetic means to compensate the defective intracellular nutrition, 
and, at the same time to maintain adequate general nutrition. 
This, as will presently be shown, can be done only by employing 
accurate methods. General hygienic and, above all, medicamentous 
means of treatment in this class of disorders play a relatively sub- 
ordinate part. 

DIABETES MELLITUS. 

The most important element in the treatment of diabetes is the 
regulation of the diet. The main objects to be accomplished are 
to maintain the general nutrition of the patient, to increase his 
tolerance for carbohydrates and, by implication, to reduce or pre- 
vent the loss of sugar in the urine. 

I have explained in the preceding section how the caloric value 
of the food can be determined and what amount of calories a nor- 
mal individual requires in order to maintain adequate nutrition. 

In case of diabetes with the loss of valuable unconsumed 
sugar in the urine, a diet that would adequately feed a normal 



DISEASES OF METABOLISM 193 

individual does not furnish the body with a sufficient caloric value, 
and as a result the patient, once the deficit is not supplied, con- 
sumes his own tissues and emaciates. Here, therefore, whenever 
possible, a metabolic study should be undertaken in order to deter- 
mine this deficit. Whenever this can be done it is of inestimable 
value, provided the figures obtained are interpreted with con- 
servatism. 

With the introduction of calorimetric methods, however, into Dangers of 
the treatment of diabetes the danger of substituting an ultra-scien- J^g^t 116 treat " 
tine routine for the old-fashioned and venerable, though altogether 
unscientific, routine of feeding every diabetic on a diet containing 
no starches or sugars, has been created. For the clinician the 
proper treatment of the case has only begun when the metabolic 
study is completed; as, to him, individual peculiarities and divers 
complicating factors that determine deviations from the metabolic 
schedule must be included in the calculation. It is well to realize, 
moreover, that the general practitioner cannot perform these meta- Difficulties of 
bolic studies in each case of diabetes that comes under observa- metabofic °cal- 
tion. He has neither the time nor the facilities, nor possibly the culations 
training, nor, above all, in most cases the co-operation of the pa* 
tient to do this work; for to properly carry out a metabolic study 
the patient should be under absolute and rigid control for several 
successive days, or better, weeks, preferably in a hospital. Never- 
theless before discussing the practical methods that can be em- 
ployed, and that have evolved from an immense number of accurate 
studies, the principles that underlie such a metabolic calculation 
may be briefly described, for they should be familiar to every physi- 
ician. The following case report [quoted from the authors "Clini- 
cal Urinology'' (Cleveland Press page) 73] may serve as an il- 
lustrating prototype of a metabolic study in a case of diabetes : 

Mrs. W. P. Weight 60* kilo. Calories required for adequate Example of a 
nutrition, 60 X 35 = 2,100. metabolic cal- 

. ,. . . . t culation in 

Average diet on six successive days : diabetes 

Proteids 150 gm. X 4.1 — 615.0 cal. 

Carbohydrates 190 gm. X 4.1 = 779.0 cal. 

Fats 110 gm. X 9.3 = 1023.0 cal. 

Total caloric intake = 2417.0 cal. 

The patient's daily average sugar 
excretion on four successive 
days on this diet was 160 gm. 
This amount calculated in 
calories must, therefore, be 
deducted as follows: 
♦The figures are given in round numbers throughout in order to 



194 DISEASES OF METABOLISM 

Average daily sugar excretion. . .160 gm. X 4.1= 656.0 cal. 

Calories, utilized = 1761. cal. 

Instead of receiving, therefore, the full caloric value required, 
i. e., 2,100 cal., the patient, owing to the loss of sugar, only util- 
ized 1,761 cal., although the diet represented 2,417 cal. This 
means a deficit of 2,100 — 1,761 = 339 cal. And these deficient 
calories unless furnished in additional food must be supplied from 
the destruction of the patient's proper tissues. 

One can further readily calculate what proportion of this deficit 
was made good from the albumin of the patient's tissues. 
facilitate the calculation. 

what from the fat (for the patient lost weight on this diet), and 
the diet can be regulated accordingly. All one has to do is to de- 
termine the nitrogen output in the urine and feces and compare 
it with the nitrogen intake (food nitrogen). 

This patient, for instance, received in the daily diet 150 gm. 
of albumin, and as albumin contains 16 per cent, of nitrogen, this 
amount contained 24.0 gm. of nitrogen. On this diet the patient 
excreted a daily average of 23.7 gm. of N. in the urine and 3.01 
gm. of N. in the feces, making the total N. output 23.7 + 3.1 = 
26.8 gm. of N. The nitrogen output, therefore, was greater by 2.8 
gm. (26.8 — 2.4 = 2.8) than the N. intake, and this excess must 
have been derived from the patient's own albumin. These 2.8 gm. 
of N. are contained in 17.5 gm. of albumin (2.8 X 100 -f- 16 = 
17.5). 

As 17.5 gm. of albumin can produce only 71.75 calories (17.5 
X 4.1 = 71.75), there still remain 268.25 (339 — 71.75 == 268.25) 
of the 339 deficient calories to be accounted for. As these must 
have been derived from the patient's fat, one can readily determine 
by dividing 268.25 by 9.3 (the caloric value of one gramme of 
fat) that 268.25 -f- 9.3 == 28.8 gm. of the patient's fat were con- 
sumed. 

The patient, therefore, on a diet valued at 2,417 calories, i. e., 
considerably more than the calculated value necessary to adequate- 
ly nourish a normal subject of 60 kilo (2,100 cal.), lost 17.5 gm. 
of her own albumin and 28.8 gm. of her own fat. 
Vicarious If it were true that a diabetic could use none of the sugar that 

feeding enters the blood stream, the question of feeding such a case would 

be theoretically a very simple one. One would have to exclude the 
carbohydrates and replace them by proteids and fats of sufficient 
caloric value to make up the caloric deficit. In the case which is 
quoted, for instance, the patient would have to receive 17.5 gm. of 
albumin and 28.8 gm. of fat, in addition to the proteids, fats and 
carbohydrates enumerated in the above diet. 



DISEASES OE METABOLISM 195 

As a matter of fact only a small minority of cases of diabetes Necessity of 
are altogether unable to utilize any of the sugar. These are very some^arbo- 
grave instances that are fortunately rare, and would be still less hydrate 
frequent if many milder cases were not transformed into grave 
ones by injudicious dieting. The great majority of patients can 
utilize some of the sugar and it is generally bad practice to with- 
hold this food permanently; for aside from the glycosuria, the 
digestive function, the comfort of the patient, and above all the 
formation of acetone bodies (see below) must be considered. 

In order to know how much sugar these patients can safely take The boundary 
without over-taxing their sugar metabolism, it is, however, neces- of tole / a ?J ce » 
sary to determine, as a preliminary step, the tolerance of each case 
for carbohydrates, or the so-called boundary of assimilation, and 
to feed the patients accordingly. 

In order to do this the patient is given what may be called a Diabetic test 
diabetic test meal. This consists of a series of articles that are free m 
from carbohydrates, plus a weighed portion of some carbohydrate 
food. The following table incorporates the most important carbo- 
hydrate free articles of food that can be used to arrange such a 
test meal. I give this diet list in this place in full, because, as 
will be presently shown, the articles included therein must often 
be utilized to the exclusion of everything else in the treatment of 
diabetes (see Table II). 

TABLE II.* 

ARTICLES OE FOOD PRACTICALLY FREE FROM CARBOHYDRATES. 

Fresh Meats. — All the muscular tissues of mammals and birds, 
braised, boiled or roasted with their own gravy, with butter, with 
meal or flour; fresh mayonnaise or other sauces made without 
flour — warm or cold. 

Inner Parts of Animals. — Tongue, heart, lungs, brain, calf's 
spleen, kidney, marrow. Liver of calf, game and poultry up to 
100 grammes (weighed after cooking). 

External Parts of Animals. — Feet, ears, snout and tail of all 
edible animals. 

Conserved Meats. — Dried and smoked meats, smoked and salted 
tongue, pickled meats, ham, bacon, tinned meats. 

Sausage. — All varieties, if free from bread or flour. 

Fresh Fish. — All fresh and salt water fish, boiled or grilled 
or served with flour-free sauce. Fresh melted or browned butter 
may be taken at the same time. If the fish is cooked in bread 
crumbs, the latter should be removed before eating. 



*Quoted in part from von Noorden, "Diabetes." 



196 DISEASES OF METABOLISM 

Conserved Fish. — Dried, salted, or smoked fish, such as cod, 
shell fish, herring, mackerel, sole, plaice, salmon, sprats, eels, etc.; 
also pickled herrings, sardines in oil, mackerel in oil, anchovies, 
sardellen, tunny. Caviar. 

Mussels and Crustacea. — Oysters, mussels, lobster, crab. 

Eggs. — From all birds, raw or cooked in various ways, but with- 
out added flour or meal. 

Fats. — Of animal or vegetable origin, e. g., butter, lard, fat of 
roast meats, margarine, olive oil, usual salad oil, cocoa butter, 
goose fat. Cod liver oil. 

Cream. — Good fat, rich cream, sweet or sour, as drink or added 
to solid foods or to drinks up to about 200 cc. a day. For cook- 
ing purposes cream may be substituted for flour when making spe- 
cial dishes of meat, fish, vegetables and eggs. 

Fresh Vegetables. — Salads ; lettuce, endives, cress, dandelion, 
purslane. 

Aromatic Herbs. — Parsley, dill, thyme, pimpernell, mint, leek, 
garlic, celery. 

Fruits, Roots and Stalks. — Gherkin, tomato, young green beans, 
vegetable marrow, onions, radishes, white and green asparagus, 
hops, Brussels sprouts, celery (except the root), young rhubarb 
sprouts. 

Blossoms and Flowers. — Cauliflower, Brussels sprouts, arti- 
choke. 

Leaves. — Spinach, sorrel, cabbage, red beet. 

Fungi. — Fresh mushrooms, truffles in usual quantities. 

Fruits. — Bilberries, unripe gooseberries, when prepared with 
saccharin instead of sugar. 

Conserved Vegetables. — Asparagus, haricot beans, cut beans, 
salted gherkins, pickled gherkins, peppered gherkins, mixed pickles, 
sauerkraut, olives, champignons and any prepared vegetables of 
those groups already mentioned. 

Condiments. — Salt, white and black pepper, cayenne, paprika, 
curry, cinnamon, clove, nutmeg, English mustard, saffron, caraway, 
caper, vinegar, citron. 

Soups. — Meat soups prepared from fresh meats or meat ex- 
tracts, with the addition of green vegetables, asparagus, eggs, frag- 
ments of meat, marrow, liver, Parmesan cheese or other foods 
contained in this table. 

Desserts. — Prepared from eggs, cream, almonds, citron, gela- 
tine, saccharine being substituted for sugar. 

Drinks. — All varieties of spring and seltzer water. Good 
brands of brandy, rum, arack, whisky, and other fruit spirits. 

Wine. — All the well-known table wines (white and red) are 
almost sugar free — at all events those that have been kept for 



DISEASES OF METABOLISM 



197 



three or more years in casks. Bordeaux and Burgundy wines come 

under this category. White Rhine and Moselle wines are also free 

from carbohydrates. 

Tea, Coffee and Cocoa. — With cream, but with saccharine sub- 
Lemonade. — Seltzer water with lemon juice, sweetened with 

saccharin or glycerin (lsevulose may be used if specially permitted). 
A very convenient diabetic test meal can be selected from the 

above articles. The following one I use almost as a routine in 

these determinations : 

stituted for sugar. 



TYPE OF DIABETIC TEST MEAL. 

For Breakfast 

Two soft boiled eggs. 

1500 cc. of weak tea with a tablespoonful of cream. 

A beefsteak, weighing (cooked) 100 grammes. 
For Dinner — 

Bouillon with one egg. 

Boiled or fried fish and broiled chicken, the two together weigh- 
ing (cooked) not more than 250 grammes. 

A little celery. 

Boiled onions. 

Cauliflower. 

Lettuce salad with plenty of oil dressing. 

A cup of weak tea with two tablespoonfuls of cream. 

About 30 grammes of Xeufchatel or Camembert cheese. 
For Supper — 

Two boiled eggs. 

Cold asparagus, or tomatoes, or lettuce salad with plenty of 
oil dressing. 

A little bacon. 

A cup of weak tea or coffee with a tablespoonful of cream. 

If a patient is placed upon this diet for forty-eight hours, and Method of de- 
if at the end of that time the urine is sugar free, then one is deal- baSoSirf of 
ing with a mild form of diabetes and it now becomes necessary to tolerance 
determine how much carbohydrate food the patient can tolerate 
without excreting sugar. This is done by adding white bread to 
the above test meal, beginning preferably with 100 gTammes dur- 
ing the first day, distributed over two meals in 50 gramme quanti- 
ties^ and increasing this bread ration each day by 50 grammes un- 
til sugar appears in the urine. Thus, if a patient on one day ex- 
cretes no sugar after eating 3 X 50 = 150 gm. of bread, and on the 
next day passes sugar on 4 X 50 = 200 gm. of bread, then we say 
that the boundary of assimilation lies betwen 150 and 200 gm. of 



198 



DISEASES OF METABOLISM 



The three de- 
grees of 
diabetes 
The first de- 
gree, mild 
diabetes 



Two categories 
of mild 
diabetes 



The second 
degree, dia- 
betes of medi- 
um severity 



Three groups 



white bread. The diagnostic and therapeutic importance of know- 
ing this boundary of assimilation, or the tolerance for carbohy- 
drates, will presently be discussed. , 

For practical therapeutic purposes it is convenient to distin- 
guish three degrees of diabetes that may be determined as follows : 

In the first category, the mildest forms of diabetes, the sugar 
should disappear within two days after complete withdrawal of 
carbohydrate foods, i. e., as soon as the patient is placed upon 
the carbohydrate-free test meal mentioned above. To the category 
of mild cases also still belong those instances in which the patients 
fail to excrete sugar when there are added to this carbohydrate- 
free diet from 100 to 150 grammes of white bread. 

From a clinical standpoint it is important to distinguish among 
these mild cases of diabetes two groups, viz., those that occur 
in persons past middle age or old individuals and those that occur 
in very young people. The prognosis in the former class of cases 
is always better than in the latter. Individuals of the first type are 
usually moderately obese and commonly show some evidences of the 
uratic diathesis. In the young cases the neurotic type predom- 
inates, and unless great care is exercised in these individuals, they 
are apt to develop into the medium or the severe type of diabetes. 

To the second category of cases, diabetes of medium severity, 
belong those instances in which complete withdrawal of carbohy- 
drates is necessary for at least two or three weeks before the sugar 
completely disappears from the urine. Among these cases of me- 
dium severity several groups must be distinguished for practical 
reasons. 

There is one group of cases in which the withdrawal of carbo- 
hydrates not only causes the disappearance of sugar within two or 
three weeks, but also produces much general improvement in the 
condition of the patient, an increase of weight and a disappearance 
of acetone bodies from the urine (disappearance of Gerhardfs fer- 
ric chloride reaction). 

In a second group of cases, the withdrawal of carbohydrates 
again leads to the disappearance of sugar from the urine, but in 
the beginning there is considerable loss of weight, the patients feel 
weak and Gerhardt's reaction either appears for the first time or 
increases in intensity. Within a few days ? however, after the dis- 
appearance of the sugar a change for the better occurs, the weight 
again increases, the patients recover their sense of well-being and 
the Gerhardt reaction disappears. 

In a third group of cases, finally, the condition becomes ag- 
gravated at once, and while the sugar may disappear the patients 
rapidly begin to lose weight and complain of great weakness; at 
the same time the Gerhardt reaction appears and rapidly increases 



DISEASES OF METABOLISM 



199 



in intensity. In addition, such patients commonly develop diges- 
tive disorders and diarrhea. This last group of cases forms the 
transition to the third or severe type of diabetes and should be 
treated accordingly. 

In the third category, the severe type of diabetes, finally the 
sugar does not disappear, even if the patients are placed for weeks 
or months upon a carbohydrate-free diet, showing that these in- 
dividuals are unable to consume even that portion of sugar which 
is generated within their own tissues from the disintegration of 
their own albumens. Here the sugar does not disappear from the 
urine until the food albumens are considerably reduced, indi- 
cating conclusively that the albumens may be a very prolific source 
of sugar, a fact of great practical importance and one that is often 
overlooked. In the most severe type of diabetes, finally, it is alto- 
gether impossible to cause the disappearance of the urinary sugar, 
even when the patients are starved, i. e., when all food is with- 
drawn. 

The prognosis and the treatment of these three classes of dia- 
betes varies radically and each type must be discussed separately. 
In the light cases, and in the cases of medium severity, the main 
object of treatment must be to cause the disappearance of the sugar 
from the urine; for in this way the tolerance for carbohydrates 
can ultimately, as a rule, be increased and complications removed; 
whereas if the glycosuria, thanks to careless dieting, is allowed to 
persist, the cases almost invariably become aggravated. The com- 
plete withdrawal of carbohydrates is, however, rarely necessary 
as a permanent procedure, as will be presently shown. In the severe 
cases less attention should be paid to the glycosuria and more to 
maintaining the general nutrition of the diabetic patient. 



The third de- 
gree, severe 
diabetes 



General con- 
siderations 
relative to 
prognosis and 
treatment of 
the three de- 
grees of 
diabetes 



DIETETICS OF THE LIGHT FORM OF DIABETES. 



"Resting" and 
"exercising" 
the sugar 
metabolism 



In this class the principle of sparing those organs that are 
concerned with the metabolism of sugar must be enforced and here 
the plan can be adopted of first "resting" the sugar metabolism, so 
to say, for short periods of time by the complete withdrawal of 
carbohydrate food from the diet, and then gradually adding carbo- 
hydrate foods to the diet to "exercise" the sugar-destroying func- 
tions back to normal. It is hardly necessary in most cases to keep 
such patients for long on a carbohydrate-free diet. 

They should be placed at first upon a diet containing no carbo- Technique 
hydrate foods (see Table II). During this period great care should, 
however, be exercised to furnish enough calories to adequately 
nourish the patient. This can usually be accomplished without 
difficulty by supplying abundant fat. Should the patient begin to 
lose flesh upon the restricted regime, despite the ingestion of 



200 DISEASES OF METABOLISM 

enough calories,, or should very large quantities of acetqne and its 
congeners, oxybutyria and diacetic acid appear in the urine, then 
the restricted diet is to be abandoned and some carbohydrate must 
be administered. Even if no untoward symptoms appear, however, 
it is generally better after four to six weeks of restricted diet to 
allow the patients some carbohydrate food for the sake of their 
appetite and general comfort; besides it is much easier to manage 
these cases, and above all to supply adequate caloric values in the 
food, if some bread, potatoes, rice or other starchy food is allowed. 
Before the addition of carbohydrates to the diet of such cases 
the boundary of tolerance should be very carefully determined, as 
described above. They should now be kept for a time upon a ration 
containing no more white bread than corresponds to an amount 
that is somewhat below the established boundary of tolerance. 

Should sugar reappear again, then the amount of carbohydrate 
food should at once be reduced or stopped altogether until the urine 
becomes sugar-free again. If the patient bears the addition of 
white bread well for several weeks, and if no glycosuria supervenes, 
then he may safely be kept on this amount of white bread or its 
equivalent (see Table III), for many weeks or months at a time. 
From time to time a period of restricted diet should again be insti- 
tuted and the boundary of tolerance re-established. 
Equivalents of The following table indicates various articles of food containing 

white bread an amoun t f carbohydrate that corresponds to that contained in 

1900 gm. of white bread. 

TABLE III.* 

THE CARBOHYDRATE CONTAINED IN 100 GM. OF WHITE BREAD IS 
EQUIVALENT TO THE CARBOHYDRATE IN: 

2 litres of milk or buttermilk. 

120 gm. of rye or graham bread. 

200 gm. of aleuronat or gluten bread.* 



♦Diabetic Breads. — Most so-called diabetic breads contain ^ap- 
proximately 50 per cent, of carbohydrate. The vegetable albumens 
(aleuronat, roborat, plasmon, gluten) all contain about 5 per cent, of 
carbohydrate. These breads are made from such flours plus a certain 
amount (one to four parts) or ordinary flour. They should only be 
used as equivalents for white bread in the proportion of about 2 to 1. 
Their indiscriminate use, which is so popular with the laity who im- 
agine that these breads can be safely taken ad libitum, is therefore to 
be condemned as dangerous. They fulfill a useful purpose, however, 
owing to the fact that twice as much of the various diabetic breads 
can be eaten as of ordinary white or rye bread and still no greater 
amount of carbohydrate be administered. This is an advantage, inas- 
much as the bulk of the bread satisfies the craving of the patient for 
bread, and, at the same time, enables him to ingest a larger amount 
of butter than if half the quantity of white bread were permitted. Ac- 
cording to the same principle it is often of advantage to give diabetics 



DISEASES OF METABOLISM 



201 



70 gm. of zwieback. 

100 gm. of chocolate. 

80 gm. of chestnuts (peeled). 

80 gm. of flour (wheat, rye, barley, buckwheat). 

70 gm. of rice. 

70 gm. of noodles or macaroni. 

70 gm. of oatmeal. 

120 gm. of dried peas, beans, lentils. 

200 gm. of green peas. 

360 gm. of new potatoes. 

280 gm. of old potatoes. 

240 gm. of fresh apples, pears, plums ? apricots, cherries, grapes. 

400 gin. of strawberries, raspberries, gooseberries, blackberries, 
cranberries, huckleberries. 

100 gm. of figs. 

6 bananas. 

6 peaches. 

Two handfuls of walnuts, hazelnuts, almonds. 

1/3 litre of Port, Sherry or Madeira. 

1 1/3 litres of beer. 

It is clear that such large quantities of any one of these articles 
should rarely be eaten in place of bread. I have given these equiva- 
lents for one hundred grammes of white bread chiefly for the sake 
of convenience in calculation. 

Milk, bread, potatoes, cereals, diabetic breads, a little beer and 
the other articles enumerated above may be allowed sparingly, pro- 
vided their carbohydrate content is included carefully in the calcu- 
lation in such a way that for each gramme of these articles that is 
permitted a corresponding amount of white bread is withdrawn. 

In this way one should succeed in keeping these patients per- 
manently sugar-free and not infrequently in practically curing 
them; at least to such an extent that they, at the expiration of a 
year or so, can exist upon a fairly liberal diet from which only a 
few articles are to be, for all time, rigidly excluded. Among the 
latter are pastry, honey, ice cream, preserves, candy and sugar. 

Unfortunately the various substitutes for sugar that we have do 
not seem to satisfy the majority of patients, so that for the sake of 



The different 
articles of 
food 



Substitutes 
for sugar 



very porous, fluffy breads on account of their bulk; for they satisfy 
the appetite if they are cut in thin slices and buttered freely, and, 
above all, they satisfy the eye and the mind without injuring the stom- 
ach or the carbhydrate metabolism. Still another bread for diabetics, 
that contains very much less carbohydrate than either ordinary white 
bread or bread made from gluten flour and wheat or rye flour, is al- 
mond meal bread made from ground almonds, containing about 7 per 
cent, of carbohydrate, with the addition of butter, eggs, salt and spices. 
Unfortunately this bread is not very palatable, tastes more like cake 
than bread and hence is not well tolerated for an indefinite time by 
most diabetics. 



202 



DISEASES OF METABOLISM 



comfort it will nevertheless usually become necessary from time to 
time, as a concession to the patient but always with the exercise of 
careful control, to allow a little of sugar or of other sweets. 



Technique 



Low boundary 
of tolerance 



Danger of too 
much albumen 



Average meat 
and fat ration 



Addition of 
alcohol 



Starvation 
plan 



DIETETICS OF DIABETES OF MEDIUM SEVERITY. 

The cases belonging to this category must be handled with much 
more care than the light cases. The patients should at once be 
placed for at least two months upon a carbohydrate-free diet and 
after the degree of tolerance, provided they can tolerate any carbo- 
hydrate, is established at the expiration of this time the addition of 
carbohydrate food made very gradually and kept up for a short 
time only. This rule is self-evident, because sugar will almost in- 
variably appear in the urine within a week or two after the use of 
starchy foods is resumed. Broadly speaking, this invariably con- 
stitutes an indication to return to the carbohydrate-free diet. It 
will usually be found that the boundary of tolerance in these cases 
is very low, i. e., that they cannot stand more than about 50 
grammes of white bread, or its equivalent, without developing 
glycosuria. 

In such cases, moreover, particular care must be exercised that 
they do not eat too much albuminous food. The fact is not suffi- 
ciently appreciated, as stated above, that albumen may become a 
very prolific source of urinary sugar and that the addition of an 
excess of albuminous pabulum to a mixed diet undoubtedly in 
many cases reduces the tolerance for carbohydrates, whereas the 
restriction of albuminous food often increases this tolerance. 
Excessive meat-feeding, besides, favors the development of acidosis. 

The average meat ration, therefore, should never exceed an 
amount containing 150 grammes of albumen (see Table I), whereas 
the amount of fat should approximate about 200 grammes. If a 
certain amount of alcohol (see elsewhere), about 70 to 80 grammes, 
is added to the diet, and this is usually a very good plan in this 
type of diabetes, then the patient receives approximately 3,000 
calories in his food, that is, about 500 calories more than the av- 
erage requirement and enough usually to compensate for any slight 
loss of sugar that may occur in the urine. If no alcohol is given 
the fat ration may be increased by 40 to 50 grammes. 

Occasionally it is impossible in this class of cases to produce 
complete disappearance of the sugar from the urine, even after the 
patients have been on a carbohydrate-free diet for nearly two 
months. In a case of this kind a very useful plan is the one sug- 
gested by ISTaunyn, viz., to starve the patients completely for a 
period of twenty-four hours, giving them during this time merely 
a little tea or coffee or bouillon, and plenty of water. After the 
fast the patient is placed for two or three weeks upon a carbohy- 



DISEASES OF METABOLISM 



203 



drate-free diet, and it will frequently be found that now the sugar 
remains absent from the urine and that some tolerance for carbo- 
hydrates has been acquired. 

In view of the fact that no individual can, without great suffer- 
ing, great discomfort and some danger, exist indefinitely upon a 
diet consisting exclusively of albumens and fats, it generally be- 
comes necessary, sooner or later, to administer, even here, some 
carbohydrate food, even at the risk of promoting glycosuria for the 
time being. This plan should, therefore, be adopted intermittently, 
immaterial whether the carbohydrate-free diet caused a complete 
disappearance of sugar from the urine or not. Such patients, how- 
ever, should never receive more than 100 grammes of white bread, 
or its equivalent, in the twenty-four hours. 

The transition from the carbohydrate-free diet to the more lib- 
eral diet should always be very gradual and the patients should 
receive each day a little more of the carbohydrate food until the 
100 gramme limit is reached. If it is found that the glycosuria 
rapidly increases, then the carbohydrates should be gradually re- 
duced and finally stopped again. It is usually a good plan to alter- 
nate the kind of carbohydrate food, i. e., to give for some days 
bread, then its equivalent in potatoes or rice or oatmeal, etc., and 
to give only a single carbohydrate at a time; for the mixture of 
several carbohydrates generally leads to a greater excretion of sugar 
than the administration of a single one. Each individual, more- 
over, reacts differently to different carbohydrates, so that tolerance 
determinations with oatmeal "or rice or potato often reveal peculiar 
relations that may be advantageously employed in the treatment. 

Based on this fact so-called "cures" for diabetes by feeding with 
large quantities of single carbohydrates have at different times been 
advocated. Thus we have had the potato cure, of Mosse the rice 
cure, of von Duhring, the milk cure, of Winternitz, and more re- 
cently the oatmeal cure } of von Noorden. All these observers are 
reliable clinicians and good observers and all of them have re- 
ported a few cases that were decidedly benefited by this method of 
feeding. This is particularly striking, as the use of large 
amounts of carbohydrate food in diabetes is in itself paradox, and 
especially as the good results were as a rule observed in cases that 
were of the severe type, and in which the ordinary methods of die- 
tetic, hygienic and medicinal treatment had failed. The oatmeal 
cure seems to yield proportionately better results than any of the 
other plans of feeding, arid as I, personally, have had experience 
with the oatmeal cure alone, I will limit my remarks to it. 

The method of administering the oatmeal cure (as recommend- 
ed by von Noorden is the following: 250 gm. of oatmeal are 
cooked for several hours in water, to which a little salt is added; 



Intermittent 
carbohydrate 
feeding 



Gradual tran- 
sition from 
rigid to liberal 
diet 



Change in kind 
of carbohy- 
drate food 



The advan- 
tages of sin- 
gle carbohy- 
drate feeding 



Oatmeal cure 



204 DISEASES OF METABOLISM 

while the porridge is boiling, about 100 gm. of butter are added 
and later, after the boiling is completed and the mess is cooled, 
about 100 gm. of egg albumen, or a like amount of some vegetable 
albumen, may be added to the porridge while it is still on the fire. 
This soup is administered about every two hours during the day 
in such quantities that the whole amount is eaten in the course of 
twenty-four hours; in addition, the patient is permitted to take 
some brandy or claret and water or a little strong black coffee. 

It will readily be seen that it is impossible to continue this 
mode of dieting for a long time; the patients naturally soon ac- 
quire a 'distaste for the oatmeal soup and when this period comes 
the treatment will have to be stopped, as it is worse than useless to 
force it. 

As a preliminary step the type of diabetes must be established. 
I have found the following clinical classification to be convenient 
and useful. 

Type 1. In cases of this type the sugar disappears within 
two days after complete withdrawal of carbohydrates; this type, of 
course, includes patients who retain a small tolerance, i. e., that 
fail to pass sugar even when 100 or 150 grams of white bread or 
its equivalent are administered. 

The cases of Type 1 that occur in very young and in very old 
people possess special clinical significance. In the young patients 
the outlook is always more serious and they almost invariably de- 
velop the severe type unless the greatest care is exercised. In the 
old patients, in whom the diabetes is usually associated with obes- 
ity, gouty manifestations or arteriosclerosis, the outlook, on the 
other hand, is especially favorable as far, at least, as the develop- 
ment of severe degrees of diabetes is concerned. 

Type 2. — The sugar can not be made to disappear until the 
patients have been on a strict, that is, carbohydrate-free, diet for at 
[east two to three weeks. Here three subgroups can readily be 
distinguished: 

In Group 1 there occurs with the gradual reduction and final 
disappearance of the glycosuria a general improvement in the con- 
dition of the patient, an increase in weight, a reduction of the 
acetone bodies of the urine to the normal. 

In Group 2 there is an initial loss of weight, a general feel- 
ing of malaise and weakness, and the acetone bodies are excreted 
in increased quantity. With the complete disappearance of the 
sugar, however, the weight again increases, the patients recover 
their sense of well-being and the acetone bodies are reduced to 
normal. 

In Group 3, finally, the condition of the patient becomes ag- 
gravated at once and, while the sugar excretion may decrease or 



DISEASES OF METABOLISM 205 

the glycosuria disappear altogether, the patients rapidly lose weight 
and strength and develop alarming degrees of acidosis with a cor- 
respondingly large excretion of acetone bodies. Such patients, 
too, often develop digestive disorders and in unfortunate cases re- 
lapse into coma if the strict diet is persisted in. It is clear that 
they form a transition to the third or severe type of diabetes. 

Type 3. — The sugar does not disappear from the urine even 
if a carbohydrate-free diet is given for many weeks consecutively, 
showing that these individuals are unable to consume even that 
proportion of sugar which is generated within their own tissues 
from the disintegration of the body albumins. Eeduction of the 
food albumins often causes a disappearance of the sugar in the 
urine, but resumption of the normal proteid ration promptly 
causes its reappearance. The patients of Type 3 usually excrete 
large quantities of acetone and its congeners and rapidly emaciate, 
even if the caloric intake is carried far above the normal limit. 

The "Von Noorden oatmeal cure" is worse than useless in the 
mild cases of the first type, occurring in adults or in senile indi- 
viduals. These patients respond to the ingestion of large quanti- 
ties of oatmeal by an increased glycosuria and very often by severe 
digestive disturbances. 

The method is also harmful in Groups 1 and 2 of the second 
type of diabetes. I have seen cases of medium severity which 
would, in my judgment, have been converted into very mild cases 
with a high carbohydrate tolerance by judicious feeding, but which 
were converted by oatmeal feeding into severe types and remained 
so; it seems that in these cases the overtaxation of the carbohy- 
drate metabolism produces irremediable and permanent damage. 

In the juvenile cases of Type 1, as well as in adolescent cases 
of the severe Type 3, the method is distinctly useful; here bril- 
liant results, not obtainable, I am convinced, by any other method 
of feeding, are occasionally observed. 

Adults, in cases of the very severe type, do not respond so well 
to the oatmeal treatment. If certain precautions, to be presently 
specified, are observed, however, no harm can accrue from a trial. 
In view of the inefncacy of the ordinary methods of diabetic treat- 
ment in this type and in view of the occasional improvement de- 
rived from oatmeal feeding^ the plan should at least be tried. 

Whereas in juvenile patients, however, no valuable time should 
be wasted with preliminary attempts to modify the course of the 
glycosuria by the ordinary strict diet and the administration of 
the oatmeal diet should be begun as soon as possible after the 
discovery of glycosuria, in adults oatmeal feeding should be re- 
garded as a last resort and should be employed only when all other 
means, after persistent trial, have been found to be inefficacious. 



206 DISEASES OF METABOLISM 

It is much easier and safer to begin the oatmeal cure than to 
stop it. The change of diet in the beginning must be abrupt, i. e., 
nothing whatsoever must be given but the oatmeal mixture. It is 
unnecessary, as a preliminary step, to attempt reduction of the 
glycosuria by a strict diet, although as a rule the patients will 
have been on a strict diet before the oatmeal treatment is begun; 
this, in my experience, is detrimental rather than otherwise. 

In patients reacting favorably to the oatmeal diet the resump- 
tion of a general diet or of a meat-fat-vegetable diet must be very 
gradual. For a long time, often months, after the exclusive oat- 
meal feeding has been stopped, oatmeal should still remain the 
only carbohydrate eaten, and other starchy pabulum should be 
very carefully administered. It is especially precarious to mix 
carbohydrates after an oatmeal course. 

Animal proteids should always be resumed with care; for 1 
have found that particularly those patients who respond well to 
the oatmeal treatment exhibit a marked intolerance for meat, fish 
and poultry; so that even in the most favorable cases, but especial- 
ly in cases in which the sugar and acetone bodies did not disap- 
pear but were merely reduced, the addition of animal proteids is 
promptly followed by an increased glycosuria and an increased ex- 
cretion of acetone bodies. 

The oatmeal diet occasionally does harm, particularly if its ad- 
ministration is persisted in when improvement in glycosuria, po- 
lyuria, acetonuria, thirst and hunger and strength fails to appear 
within five days. It is a good rule, therefore, and a safe one, to 
give up the oatmeal attempt at the expiration of this period un- 
less such improvement has become clearly manifest. In my earlier 
experience, as expressed elsewhere, I have seen a reduction in the 
tolerance for carbohydrates, quite alarming degrees of acetonuria 
and severe digestive disturbances appear if oatmeal feeding was 
persisted in for longer than five days in cases in which the patients 
did not respond favorably within this period. 

As a precautionary measure against acidosis, from two to four 
teaspoonfuls a day of sodium bicarbonate, either alone or mixed 
with equal parts of magnesia usta, should be given throughout the 
oatmeal treatment. I also administer 10 grains of pancreas pow- 
der with one grain of sodium glycocholate four times a day during 
the period of exclusive oatmeal feeding. No laxative is ever 
needed, the oatmeal and the fat effectively promoting good bowel 
evacuations. 

The most brilliant results are obtained in children, particularly 
if the oatmeal cure is administered as soon as possible after the 
diabetes is discovered. I have seen in the last five years three cases 
of diabetes in children (see below) within two or three weeks after 



DISEASES OF METABOLISM 207 

the first symptoms of diabetes were discovered. And these three 
children, after a lapse of from three months to three and one-half 
years, are altogether well, one on a general diet, one on a partially 
restricted diet, one (the most recent one) on a diet still incor- 
porating no other carbohydrate than oatmeal. 

In cases of diabetes of longer duration children below 15 years, 
in my experience, do not fare so well. Of eleven children, with a 
diabetes of longer standing, varying in age from 7 to 14 years 
(whom I either treated myself or in whom I advised the oatmeal 
treatment) who were fed on the oatmeal diet as a last resort and 
who had been fed for periods of several months before with a strict 
diet, not one is even symptomatieally well today. Seven of them 
have succumbed to coma, one to intercurrent tuberculosis, three 
are still alive, but none of them sugar-free. 

In adolescents and adults the results have, on the whole, been 
favorable rather than otherwise. In so far as the mild cases of 
Type 1 (see above) and certain cases of Type 2 are excluded as al- 
together unsuitable from this summary, there remain only a lim- 
ited number of severe, usually quite old, cases of diabetes to be 
considered. 

In no adolescent patient have I seen permanent cessation of 
the glycosuria in the sense, namely, that a general diet could 
safely be resumed. In a considerable number of the cases the oat- 
meal diet, however, produced a decidedly favorable effect, and 
when persisted in led to a complete disappearance of the sugar, 
without much acetonuria, a result that had been impossible to ob- 
tain by any other method of feeding ; associated with these changes 
was often a marked gain in weight and strength and a disappear- 
ance of the most distressing general symptoms of severe diabetes 
and of certain of the complications (neuralgias, furunculosis, con- 
stipation, itching). 

None of these patients maintained their improvement when 
abundant proteid feeding was resumed. In so far as continuous 
feeding with the oatmeal diet is impossible, and in so far as in 
several of the cases the oatmeal ceased to be so well tolerated 
after several weeks as at first, this improvment is only relative; 
nevertheless, it is an improvement, a much-to-be desired one, and 
one, in my judgment, not obtainable by any other means. 

Even when the oatmeal diet was administered within two or 
three weeks after the discovery of the diabetes in adults or adoles- 
cents suffering from types suitable for this treatment, no such 
good results as those occasionally obtained in children under simi- 
lar conditions have ever, in my experience, been observed. 

Case 1. — Mary P., aged 8 years 6 months. Without any pre- 
monitory symptoms the child developed lassitude and "cranki- 



208 DISEASES OF METABOLISM 

ness," with great hunger^ thirst and polyuria, was taken to her 
physician on the third day after the onset of these symptoms and 
the urine found to contain abundant sugar, diaeetic acid and ace- 
tone. Twenty-four hours' quantity passed on the day following 
was 4,200 cc. I saw the child four days after the discovery of the 
diabetes, i. e., seven days after the appearance of the first symp- 
toms. For four days a strict diet had been followed. Urine analy- 
sis of the quantity collected from the seventh to eighth days: 
Quantity, 4,400 cc. ; specific gravity, 1,038; sugar, 68 grams; fer- 
ric chlorid reaction positive; acetone, 4.1 grams. Weight, 59 
pounds 4 ounces (loss of 2 pounds 4 ounces from the third to the 
seventh day). The oatmeal diet was at once administered to the 
exclusion of everything else, and the accompanying table shows 
the sequenec of events. I heard from the child's parents about a 
year and a half later; she had then been on a general diet for sev- 
eral months, only sweets and candies being excluded. A urine 
sample revealed normal conditions. The family has since then 
lived in Europe and I have lost track of the case. 

Case 2. — Elizabeth B., aged 10, suffered slight indisposition 
.with a little temperature, some epigastric tenderness and a faint 
icterus. Six weeks later she became thirsty. Urine examination 
at this time : 4,000 cc. ; specific gravity, 1,040, with a large amount 
of sugar. The child was brought to Dr. Herrick Dec. 27, 1906, 
and the oatmeal diet begun at once. Jan. 2, 1907, the urine for 
twenty-four hours was 1,000 cc. and sugar-free. The sugar entire- 
ly disappeared after three days of the oatmeal diet. On January 
14 it was determined that no sugar had been present from January 
1 to June 1 ; then for three days there was a little sugar, which 
again promptly disappeared on the oatmeal diet. The patient 
weighed 70 pounds, felt strong and was attending school. Daily 
examination of the urine had been made for six months and Nov. 
20, 1907, the father reported that, barring the occasional appear- 
ance of a little sugar in the tests that were made every day., the 
child was apparently well, the sugar never being present for more 
than three days at any time since ten months ago. "She is eating 
gluten bread twice a day and buckwheat cakes for breakfast ; fruit 
and nuts as she cares for them ; meat and eggs, all we can induce 
her to take; no milk except cream in weak tea or weak coffee." 

Case 3. — Jennie M., aged 10 years, 1 month. Sugar was first 
discovered Oct. 8, 1908, following symptoms of general weakness, 
peevishness, loss of appetite, great thirst for two weeks preceding 
first visit of Dr. Schirmer. From October 8 to October 18 strict 
diabetic diet was given. On this regime the child continued to lose 
weight, grew weaker, polyuria increased and urine remained 
"loaded with sugar." 



DISEASES OF METABOLISM 



209 



She was referred to me Oct. 18, 1908, and was sent to Michael 
Eeese Hospital. Strict diabetic diet for forty-eight hours. Sugar 
excretion during the first twenty-four hours was 45 grams; during 
the second twenty-four hours, 65 grams. (For other urinary find- 
ings, see Table 2.) October 21 the patient was put on oatmeal diet. 
The sugar excretion on four succeeding days was as follows: 40.8 
grams, 11.1 grams, 2.7 grams, grams. Under exclusive oatmeal 
diet for eight days the urine remained sugar-free. The addition 
of one pound of beefsteak to the diet caused the reappearance of 
sugar, 21.37 grams. Strict oatmeal diet caused the urine to be- 
come sugar-free again in two days. Several vegetables and a lit- 
tle fish, poultry and beef were now added to the diet, the oatmeal 
at the same time being reduced. The urine has remained sugar- 
free ever since. The acetone bodies have been reduced to normal 
figures. The child today (Jan. 16, 1909) weighs 77 pounds 8 
ounces as against 64 pounds 8 ounces three months ago, feels well 
and strong on a diet containing about 50 grams of oatmeal, about 
200 grams of meat, fish or poultry, 25 grams of bread, 25 grams 
potato, and other "allowed" vegetables ad libitum. 



DIETETICS OF THE SEVERE TYPE OF DIABETES. 

In view of the fact that it is impossible in this form of diabetes 
to cause the complete disappearance of the sugar from the urine, 
even when the albumins of the diet are greatly reduced, especial 
care must be taken to compensate for the loss of sugar by increas- 
ing the ingestion of albumins and fats, for only in this way can 
adequate nutrition be maintained. For this reason less attention 
must needs be given to reducing the glycosuria than to maintaining 
the body weight, treating complications symptomatically and ren- 
dering these unfortunate cases comfortable. In this variety of 
diabetes, to which belong most of the juvenile cases, acidosis (and 
the excretion of acetone bodies) is usually very pronounced. This 
generally constitutes a danger, because in a large proportion of 
cases coma seems to be more liable to occur when the acetone body 
excretion is great than when it is absent or small, although there 
are many exceptions to this rule. Exclusive meat-fat feeding 
seems to favor acidosis and it will be found that the addition of 
carbohydrates to the diet of such cases often, although not invaria- 
bly, causes a considerable reduction in the acetone-body excretion. 
If, therefore, such patients develop marked degrees of acetonuria, 
with oxybutyric and diacetic acid and much ammonia in the urine, 
then, above all, the exclusive meat-fat diet should be discontinued 
and, for the sake of safety and as a prophylactic measure against 
coma, carbohydrate food should be given even at the risk of increas- 
ing the glycosuria. 



Technique 



Acidosis in 
this type 



210 



DISEASES OF METABOLISM 



Carbohydrates 
of little food 
value 



The albumen 
and fat ration 



The liquid 
intake 



Smoking, 
chewing and 
atropine to 
allay thirst 



Fallacy of 
"forbidden" 
and "allowed 1 
"diabetic 
diet." 



In this class of cases carbohydrates, however, have practically 
no food value, because they are promptly re-excreted in the urine. 
They must be considered merely as a welcome addition to the diet 
and one that enables the patient to eat enough of the necessary 
albumens and fats to maintain nutrition. It will often be found 
that the complete withdrawal of carbohydrates not only destroys 
the appetite, but produces digestive disorders that are often fatal 
in their consequences. In general, these patients should be allowed 
considerable albuminous food up to 150 grammes, the maximum of 
fat, considerable alcohol and, in addition, about 50 to 60 grammes 
of bread or its equivalent. This liberal feeding should be inter- 
rupted from time to time by placing the patients for two or three 
or more weeks upon a rigid diet; then the carbohydrate portion of 
the food should again be gradually increased. One will often be 
gratified even in these severe cases to find that their tolerance for 
carbohydrates is greater after such a period of carbohydrate with- 
drawal than before. In this type of diabetes, particularly, careful 
metabolic studies, preferably carried out in an institution, are often 
of inestimable value in prolonging life. 

The amount of fluid in this class of cases should be regulated in 
such a way that the specific gravity of the urine, broadly speaking, 
is kept up to, or brought down to, 1025. The liquid intake should 
in general be proportionate to the ingestion of albumens and the 
corresponding excretion of urea; for the urea largely determines 
diuresis. Excessive water drinking is to be condemned in severe 
diabetes on account of the danger of gastric dilatation and of the 
strain upon the heart and arteries that results from the abundant 
ingestion of water. Very often diabetics acquire the habit of drink- 
ing large amounts of liquid. They should be educated to control 
this craving and if necessary may be advised to chew gum or smoke 
a little in order to deaden the sensation of thirst. Atropine sul- 
phate in one-two-hundredth, grain doses also often fulfills a like 
purpose. 

It will be seen from all that has been said that the exact regula- 
tion of the diet in diabetes must vary according to the type and the 
degree of the disease, and according to individual peculiarities, the 
presence or absence of complicating diseases, the age of the patient 
and his ability or willingness to submit to rigid control. Conse- 
quently no mathematical formula, no "Diabetic Diet" giving "for- 
bidden" and "allowed" articles can be arranged for feeding every 
case of diabetes. Until very recently the dangerous routine habit 
of placing each case of diabetes for indefinite periods upon a diet 
containing no carbohydrates was universally in vogue. As a result 
innumerable diabetics were literally starved to death. Nowadays 
we have learned, as shown above, that a diabetic not only can, but 



DISEASES OF METABOLISM 211 

should^ in the great majority of cases, at least from time to time, 
enjoy the benefit of carbohydrate feeding. 

MEDICAMENTOUS TREATMENT OF DIABETES. 

A large number and a great variety of remedies have at differ- 
ent times been recommended for the cure of diabetes. None, how- 
ever, can exercise a curative effect upon the disease proper and only 
a few appreciably influence the excretion of sugar. Most of the 
reports on the effect of the different medicines that have been used Inaccuracy of 
in diabetes have been made without sufficient dietetic control, and If^Jg ™ rug 
for periods of time that were far too short to rule out the uncer- diabetes 
tainties that always arise in regard to the effect of a remedy in a 
disease that is subject to so many spontaneous fluctuations as dia- 
betes. In interpreting, furthermore, the efficacy of any drug in 
diabetes, a disorder that, especially in its milder forms, is so The sugges- 
markedly influenced by emotional and psychic states, the element tlve element 
of suggestion must always be considered, particularly when a new 
drug of much vaunted efficacy is tried for the first time. 

Some of the remedies that are actually capable of reducing the Remedies that 
glycosuria act by curtailing the appetite and by interfering with ^\^ an | j^" 
the assimilation of food. As soon as a patient, owing to such a range the 
drug effect, eats less food, especially carbohydrate or albuminous lges lon 
food, then the sugar excretion may very readily become reduced; 
incidentally, however, serious harm may be done the patient, owing 
to the malnutrition and the irritation of the gastro-intestinal tract, 
or the liver, that is produced by the medicine. Other remedies, 
again, exercise a beneficial effect upon certain functions of the 
liver, the cardio-vascular apparatus, and, above all, the nervous 
system, so that they possibly improve the general condition of the General tonics 
patient, act as a general tonic and hence actually enable him to 
destroy more sugar than before. These effects are, however^ as will 
readily be understood, very indirect and in most cases transitory. 
One should, therefore, be especially careful not to place too much 
reliance on drugs in the treatment of diabetes, nor to misinterpret 
a temporary reduction in the sugar excretion as due to the drug 
effect alone, for otherwise the temptation may be created to neglect 
the all-important dietetic treatment. 

The fact that there is not, so far as we know to-day, any proper 
anti-diabetic remedy should not, however, discourage us from using 
those drugs that we know to be capable of favorably affecting the 
general health of the patient, counteracting or remedying compli- 
cations or, above all, removing distressing or dangerous symptoms, 
chief among them the glycosuria. To enumerate all the drugs that 
have been recommended would be futile, so that only those may be 



212 



DISEASES OF METABOLISM 



Opium and its 
alkaloids 



Dose and ad- 
ministration 



Action of 
opiates 



Nervous seda- 
tives 

Bromides 

Chloral 

Phenacetin 

Sulphonal 

Valerian 

Salicylic acid 
preparations 



discussed in this place that have empirically vindicated their claims 
to usefulness in the treatment of diabetes. 

Chief among the valuable drugs are opium and its alkaloids. 
By the aid of opium the last traces of sugar can, without doubt, 
often be removed from the urine in cases that do not become alto- 
gether sugar-free on a restricted diet. In cases of medium severity 
particularly, that are existing upon a restricted diet, but that still 
excrete some sugar, it often reduces the glycosuria. It does not, 
however, seem to exercise any appreciable effect upon the sugar ex- 
cretion in diabetics who are eating carbohydrate foods. The effect 
of the drug can never be absolutely relied upon and its action is 
always uncertain; for occasionally it exercises no influence at all, 
even in the cases specified above. Its effect is never permanent; for 
when its use is stopped the glycosuria reappears and usually in- 
creases rapidly, only to disappear again, everything else remaining 
equal, when opium is resumed. Many patients rapidly wear the 
drug out, so that the dose must be continuously increased if its 
effect upon the sugar excretion is to be maintained. Herein lies 
the chief danger from the use of opiates, especially if the patients 
know what they are taking. 

The dose should be large from the beginning, i. e., at least half 
a grain (0.03 gm.) of the extract should be given three or four 
times a day, preferably in combination with the extract of bella- 
donna, one-twelfth grain (0.005 gm.) or atropin sulphate one one- 
hundredth grain (1 mg.). Some clinicians prefer codeine, others 
morphine in appropriate doses, but, in my experience the best ef- 
fects are undoubtedly obtained from the extract of opium admin- 
istered as above. 

It is probable that opiates act chiefly by their sedative power 
and not by any specific effect upon the carbohydrate metabolism, 
although some investigations seem to indicate that opiates inter- 
fere with the disassimilation of the tissue albumens and hence 
prevent the organism from splitting off sugar molecules from the 
tissue proteids. This would explain their good effect in patients 
living upon a carbohydrate-free diet in which the urinary sugar 
is undoubtedly derived from the catabolism of the albumens proper 
A number of other remedies have been given for their seda- 
tive effect upon the nervous system, chief among them, bromides, 
chloral, phenacetin, sulphonal, valerian, etc. Many of these drugs 
undoubtedly act beneficially in the neurotic or neurasthenic types 
of the disease, but in most cases they are inert and do more harm 
than good by irritating the gastric mucosa and deranging the di- 
gestion. 

Next in importance -to the opiates are the preparations of sal- 
icylic acid, given either as sodium salicylate, in doses of from ten 



DISEASES OF METABOLISM 



213 



to thirty grains (0.6 to 2 gm.) or as aspirin, in doses of from 
thirty to forty grains (2 to 3 gm.) several times a day, after eating. 
These drugs act differently than the opiates, for their effect be- 
comes apparent precisely in those cases that are eating some carbo- 
hydrate food; they seem to increase the boundary of tolerance for Mode of action 
carbohydrate foods, and thus enable the patient to utilize more of 
the alimentary starches. These drugs, too, should be given in large 
doses, as indicated above, in order to do any good. They are strict- 
ly contra-indicated in diabetics suffering from gastric or renal Contra-indi- 
disorders; and as many diabetics, especially of the severe type, catlons 
suffer from these complications, their usefulness is limited. Some 
skeptics go so far as to claim that the salicylate preparations do 
good chiefly by deranging the stomach and hence interfering with 
the proper assimilation of food, and that they reduce the gly- 
cosuria in this way, simply because, upon their administration, 
less of the ingested carbohydrate pabulum is absorbed. It is hard 
to disprove this criticism. 

Jambul occasionally acts very well in diabetes in a manner Jambul 
similar to the salicylates, i. e., it aids in increasing the boundary 
of tolerance. Its action, however, is very uncertain and its effect 
transitory. One can never predict in advance, therefore, whether 
or not jambul is going to be effective. Patients, moreover, wear 
this drug out very rapidly, so that if it is administered at all, it 
should be given interruptedly, i. e., for two or three weeks at a 
time and then not again until after an intervening period of at 
least four or six weeks. Leading authorities report sufficiently 
good effects from the use of jambul to warrant its trial in every 
case that does not satisfactorily yield to dietetic treatment, opium 
or salicylates. The drug may be given in the form of the dry Dose and ad- 
powder in the dose of five to thirty grains (0.3 to 2 gm.) three 
or four times daily in capsules, gradually increasing the quantity 
until as much as an ounce (32 gm.) is given a day. A much, 
more reliable and pleasant preparation is the maceration with 
water which may be prepared as follows:* 200 grammes of dried 
jambul fruits, including the seeds, are finely powdered and mac- 
erated in two litres of water (to which, 10 gm. of salt and 4 gm. 
of salicylic acid are added) at 37° to 40° C. The watery extract 
is filtered off and 100 cc. of the fluid taken cold every morning 
on an empty stomach, and the same dose again in the evening 
before retiring. The salicylic acid is added merely as a preserva- 
tive. 

Alkalies are always useful in diabetes and I have made it Alkalies 
a practice to give from five to thirty grains of sodium bicarbon- 



ministration 



♦Von Noorden. 



214 



DISEASES OF METABOLISM 



Mode of action 



Mineral 
waters 



Life in Carls- 
bad, Marien- 
bad, Vichy 



Dangers of 
sort treat- 
ment 



Iodide of 
potash 



ate, or of calcium carbonate, two or three times a day to every 
case of diabetes for indefinite periods of time. Alkalies in the 
first place effectively aid in counteracting the acidosis that is so 
frequently met with in diabetes; in this sense a continuous alkali 
therapy may be considered a useful prophylactic measure against 
the development of severe acidosis, which notoriously often leads 
to the development of coma. Aside from their effect upon the acid 
intoxication alkalies must also be considered an hepatic stimulant, 
and there is much experimental evidence to show that they in- 
crease intracellular oxidation and hence, we must assume, pro- 
mote the destructive metabolism of circulating carbohydrates. 

The effects occasionally derived from the use of many of the 
mineral waters, natural or artificial, that are so popular in the 
treatment of diabetes, must in large part be attributed to the al- 
kalies they contain. To this category belong especially waters like 
Vichy, Marienbad and Carlsbad. 

It is important, however, to appreciate that the benefits de- 
rived from a sojourn in Carlsbad or Marienbad or Vichy, or any 
of the other watering places, can only in part be attributed to the 
effect of these alkaline waters. The resort treatment of diabetes 
of certain types is without doubt highly beneficial; but this is due 
in great part to the careful regulation of the diet which can be 
carried out without hardship to the patient in such resorts; to the 
respite from worry and from the strenuous business life ; to the out- 
door existence and the pleasure derived from a vacation in a pleas- 
ant watering place ; not to speak of the benefits that accrue to the 
patients from placing themselves under the care of resort physi- 
cians who are usually particularly skilled and experienced in the 
management of this disease . There is one danger in the resort 
treatment of diabetes, viz. ? that many cases, particularly of the 
lighter type, imagine that a few weeks in Carlsbad, Marienbad or 
Vichy under a careful regime will neutralize the bad effects ac- 
cruing from injudicious dieting during the rest of the year, so that 
many patients imagine that they can divorce themselves from all 
restrictions, provided they return to the resort for some months 
each year. This form of optimism is to be seriously discouraged. 
That the drinking of the waters in these resorts alone does not 
produce the beneficial effects in diabetes is made very apparent by 
the indifferent results obtained from their use if they are taken 
at home, bottled, or in the form of artificial salts. 

Iodide of potash sometimes acts beneficially in diabetes, par- 
ticularly in two types, viz., those that are due to arterio-sclerosis, 
possibly involving the arteries of the pancreas, and those that are 
due to syphilis (central lesions, syphilitic pancreatitis or hepatitis). 
The remedial action of iodides in arterio-sclerosis has been fully 



DISEASES OF METABOLISM 



215 



discussed in the section on this disorder. Their good effect as 
antihietics is self-evident. Every case, therefore, presenting evi- 
dences of arterio-sclerosis, or presenting a suspicious syphilitic his- 
tory, should be given the benefit of an energetic iodide treatment, 
care being taken, of course, above all things that the stomach and 
intestine are not deranged (see Syphilis). 

Sulfopyrin is almost a specific against iodism. The proper 
dosage is 1 g. three to four times a day in case iodism is already 
established. As a prophylactic one or two tablets a day may be ad- 
ministered. The remedy is particularly useful in counteracting the 
tendency to catarrh that is so distressing a symptom of iodism. 

Mercury seems to act less beneficially in diabetes due to syphilis. 
This must be attributed to the fact that the diabetic manifestation 
in syphilis is always a late sign^ presumably due to arterial 
changes involving the central nervous system or the pancreas and 
producing degeneration of portions of these organs. Iodide of 
potash can here possibly be effective, whereas mercurials are usu- 
ally without effect. Bichloride of mercury has been recommended, 
but the drift of opinion among reliable clinicians seems to speak 
against its efficacy. Given hypodermically it not infrequently pro- 
duces disagreeable sequelae, owing to the vulnerability of the skin 
and subcutaneous tissues in diabetes and the tendency in this dis- 
ease to the development of skin lesions. Its use, therefore, had 
better be eschewed. 

Various drugs have been recommended whose efficacy should 
be attributed to their action as intestinal antiseptics, and sympto- 
matically they occasionally do good. To this group belong lactic 
acid, creosote and other phenol preparations. Their effect is very 
uncertain and very little benefit generally accrues from their use. 

General tonics, such as quinine, arsenic and iron, are commonly 
used in diabetes. They occasionally improve the anemia and pos- 
sibly stimulate the nervous system to increased activity, but I have 
never been convinced that they exercise any appreciable effect upon 
the course of diabetes nor upon the amount of sugar excreted in the 
urine. 

Organo-therapy on theoretical grounds should be efficacious in 
diabetes. However seductive the use of pancreas preparations or 
of combinations of pancreas with muscle or with liver or with 
salivary gland-extract may appear, practically nothing of definite 
value has so far been observed from their administration. Pan- 
creas is occasionally useful, as will be shown in another paragraph, 
in the treatment of the steatorrhea of diabetes, but it has no effect 
upon the glycosuria. I reported some cases in which the boundary 
of tolerance seemed to be raised by the use of pancreas-muscle 



Sulfopyrin 



Mercury 



Bichloride of 
mercury 



Intestinal anti- 
septics 
Lactic acid 
Creosote 
Phenol prep- 
arations 

Quinine 
Arsenic 
Iron 



Organo- 
therapy. 



Pancreas alone 
and combined 
with liver, 
muscle, sali- 
vary glands 



216 



DISEASES OF METABOLISM 



Liver extracts 



Brewer's 
yeast 



Substitutes 
for sugar 

Saccharine 

Dulcin 

Crystallose 



Levulose 



Alcohol 



extracts,* but observations made subsequently in a larger number 
of cases have failed to support the first observations. Liver ex- 
tracts and brewer's yeast have been used, but the optimistic claims 
advanced in the beginning have never been vindicated, although 
yeast often favorably influences the furunculosis of diabetes. Nev- 
ertheless organo-therapy appears to be a very hopeful field and 
while nothing tangible has so far been accomplished, we may hope 
some day to discover an efficient organo-therapeutic method of 
combating diabetes. 

Among the drugs that may, finally^ be used in the treatment of 
diabetes may be mentioned some of the preparations that take 
the place of sugar. To this group belong chiefly saccharine, dulcin 
and crystallose. Saccharine is the sulphonid of benzoic acid and 
is three hundred times sweeter than ordinary sugar. In very 
small quantities, therefore, it is often useful to sweeten coifee, tea 
and lemonade, preserves and other desserts. It also forms an im- 
portant constituent of a variety of diabetic relishes, wines, candies, 
etc. The patients, however, soon tire of this remedy and argue 
that while it is sweet it does not take the place of sugar ; moreover, 
it has been shown that saccharine is not without effect upon the 
kidneys, for it not infrequently produces irritation of the renal 
epithelia. It should, therefore, be given carefully, occasionally 
stopped and replaced by crystallose or by dulcin. The latter rem- 
edy, paraphenol carbamid, is not so sweet as saccharine; moreover, 
it irritates the liver and occasionally produces icterus. Its taste, 
however^ is more agreeable than that of saccharine. I have fre- 
quently used the drug without ever seeing any bad effects from so 
doing, provided it is not given in doses of more than 2 gm. a day. 

Occasionally a patient who is altogether intolerant to dextrose 
can take levulose for a time with impunity. If this is the case 
the latter sugar is an invaluable aid in feeding diabetics. Be- 
fore administering it one should carefully determine, however, 
the boundary of tolerance of the patient for this sugar.* If ali- 
mentary glycosuria follows its administration promptly, then it 
must be considered as dangerous as dextrose and should be dis- 
continued. 

Alcohol possesses a high caloric value, one gramme furnish- 
ing 9 calories. As a food, therefore, it can, to a limited extent, re- 
place other articles. 



•"New York Medical Journal," 1904. 

•For the normal boundary of tolerance for different sugars see 
Croftan: "Clinical Urinology" (Cleveland Press), p. 65. 



DISEASES OF METABOLISM 



217 



100 calories are furnished by : 

14.3 gm. of alcohol (100-S-7). 
10.75 gm. of fat (100 -h 9.3). 

24.4 gm. of proteid (100 -f- 4.1). 

24.4 gm. of carbohydrate (100-^-4.1). 
As the digestion of fats is usually improved by taking a lit- 
tle alcohol, preferably in the form of brandy or whisky, alcohol 
is particularly useful as a stomachic in diabetes and as a substi- 
tute for some of the fat in cases that are living upon a meat-fat 
diet. As a general heart and nerve tonic it also has its place, 
especially in patients who have been used to some alcoholic stimu- 
lant all their lives. In such individuals, especially if they are 
advanced in years, the withdrawal of alcohol is decidedly bad prac- 
tice. More than forty to fifty grammes per diem, however, should 
rarelv be allowed. 



EXERCISE IN DIABETES. 

In addition to the dietetic and medicamentous treatment of Importance of 
diabetes one should recognize that certain other elements in the erc i se 
general management of the disease are of great importance. Thus 
the amount of exercise that a diabetic takes should be carefully 
regulated. Muscular exercise by increasing the carbohydrate meta- 
bolism in the muscles is, in certain cases, capable of reducing the 
glycosuria. Light muscular exertion, partaking of the character 
of out-door sports, is always to be preferred to in-door calisthenics 
or forced exercises; for ? in the former case, the pleasure derived 
from the exercise, i. e., the joyful psychic stimulation as well as the 
outdoor life, both act beneficially. No violent exercise should be 
permitted, for in diabetes any over-strain is dangerous. The 
amount of exercise should be made altogether dependent upon the 
general nutrition of the patient, the condition of the heart, the 
blood vessels, the kidneys and the nervous system. 

The urine should always be carefully inspected in order to Control of ex- 
control the effect of exercise. As soon as the nitrogen excretion ^^ y 
increases, muscular exercise should be reduced or stopped; for, 
whatever benefits are to accrue from muscular exercise should be- 
come manifest by an increased destruction of sugar, i. e., by a re- 
duction of the glycosuria, and not by an increased destruction of 
body albumen, i. e., by an increased excretion of nitrogen (urea). 
In order to obtain the optimum effect from exercise it is best to 
administer the carbohydrate ration, in cases living on a semi-re- 
stricted diet, immediately before muscular exercise is indulged in, 
and to continue the exercise for an hour or two thereafter; for it 
has been shown that during muscular exercise more of the sugar 
is consumed and utilized than during periods of rest. 



218 



DISEASES OF METABOLISM 



Massage 



Stomatitis 
Gingivitis 
Pyorrhea 
Caries of teeth 



Toilet of the 
mouth 



Fetor 



If gymnastics or outdoor exercises are contra-indicated on 
account of complications about other organs, then massage occa- 
sionally produces a very beneficial effect upon the excretion of sugar 
and the general well-being of the patient, although its effects are 
not by any means so striking nor so reliable. Here, again, the 
carbohydrate ration can to advantage be administered before the 
massage treatment is applied. In the severe type of diabetes very 
active muscular exercise must be eschewed. Such patients should 
be advised to lead a quiet life ? both physically and psychically, for, 
in severe diabetes, as has been repeatedly stated, any strain and 
unrest, either emotional, mental or physical, should be avoided. 

TREATMENT OF THE COMPLICATIONS 
AND SEQUEL/E OF DIABETES. 

Most of the complications of diabetes disappear with a reduc- 
tion of the glycosuria and an improvement of the general condi- 
tion of the patient. Sometimes a more rigid diet must be ordered 
for a time, on account of complications, than would otherwise be 
administered, so that a mild type of diabetes, for instance, must 
be treated like a case of medium severity. Occasionally, however, 
it becomes necessary to employ special methods for the relief of 
very obstinate, very distressing or particularly dangerous symp- 
toms. 

The stomatitis, gingivitis, pyorrhea, the loosening and caries 
of the teeth may be due either to localized infections or to tropho- 
neurotic influences. These mouth manifestations are among the 
most distressing symptoms of diabetes and it is important that 
every case of diabetes should, from the beginning, be instructed 
carefully in regard to the possibility of mouth complications, and 
taught how to attain mouth asepsis and to perform the proper 
toilet of the teeth and gums. After each meal a diabetic should 
rinse his mouth and cleanse his teeth, preferably with a 3 per cent, 
solution of sodium carbonate in warm water to which may be added 
as a flavor a few djrops of the tincture of eucalyptus or a little 
menthol. Mechanical irregularities of the teeth should be cor- 
rected early, by choice during the aglycosuric period. All articles 
of food that can mechanically scratch or injure the gums and very 
hot beverages should be forbidden. A hard tooth brush should 
never be used. 

Excessive fetor may be corrected by using the following mouth 
wash: 



3 



Beta-naphthol, 
Sodium biborate, 
Peppermint water, 
Distilled water, 
M. Sig. Apply locally. 



0.2 gm. 
20.0 gm. 
200.0 cc. 
1,000.0 cc. 



DISEASES OF METABOLISM 



219 



If the gums are painful and bleeding the following mouth wash Bleeding and 



is useful : 

9 



painful gums 



20.0 cc. 



root, 



10.0 gm. 
1,000.0 cc. 



Tincture of opium, 
Chlorate of potash, 
Biborate of soda, each, 
Decoction of marshmallow 
M. Sig. Apply locally. 

The care of the skin is always of great importance in diabetes 
on account of the tendency shown in this disease to the develop- 
ment of furunculosis,* erysipelatous infections, acne, eczema and 
gangrene. Lukewarm baths, preferably with the addition of soda 
or of salt, are exceedingly useful. Following such a bath the pa- 
tient's skin should be carefully dried with soft warm cloths and 
treated with cocoa butter or oil. Severe rubbing, owing to the 
vulnerability of the skin, should always be avoided. Patients with 
diabetes should frequently change their underwear and the greatest 
cleanliness of the surfaces of the body should be promoted. 

Pruritus, either general or localized, especially about the geni- 
tals, is one. of the earliest, most distressing and most obstinate 
symptoms of diabetes. General pruritus is presumably due to 
irritation of the cutaneous nerves by circulating sugar. In most 
cases its intensity fluctuates with the degree of glycosuria and the 
symptom frequently disappears without further interference when 
the urine becomes sugar-free, only to reappear again, however, 
when more liberal carbohydrate feeding is instituted and the hyper- 
glycemia increases. The best remedy for internal use and almost 
a specific is sodium salicylate, in doses of thirty grains (2 gm.) 
several times a day. Local applications are of little value in gen- 
eral pruritus, but a very useful wash is the following: 

Corrosive sublimate, 0.2 

Glycerine, 20.0 

Aqua coloniens. 100.0 

Spirit, vini, ad, 400.0 
M. S. Wash. Apply locally. 

In pruritus around the genitals, due in many cases to the de- 
velopment of fungi (mycosis vulvce) and usually due to lepto- 
thrix, the reduction of the glycosuria, sodium salicylate internally 
and anodyne powders or ointments applied locally usually relieve. 
A 5 per cent, cocaine ointment or a 3 per cent, eucaine ointment, 
or a dusting powder containing 10 per cent, of orthoform, com- 



Skin lesions 



Pruritus 



♦Yeast internally is in some cases an efficient remedy against dia- 
betic furunculosis. 



220 



DISEASES OF METABOLISM 



Dyspeptic 
symptoms 



Gastric irri- 
tation 



Catarrh of 
the bowel 



bined with frequent washing of the parts without rubbing or 
scratching, usually promptly produce relief. 

Dyspeptic symptoms arising in the course of diabetes always 
call for particular attention. First, because diabetics more than 
sufferers from any other disease are dependent for the maintenance 
of their existence upon an intact gastro-intestinal tract. Second, 
because dyspepsia, especially in severe types of diabetes, is fre- 
quently a precursor and a determining factor in the development 
of coma. Dyspeptic symptoms not uncommonly arise from monot- 
onous^ one-sided feeding, e. g., from an excessive meat-fat diet, or 
simply from over-loading the stomach with food (polyphagia) or 
water, with resulting functional over-taxation and mechanical dila- 
tation of the stomach with all that entails. 

In very severe cases of gastric irritation the best plan of all is 
to withdraw food completely for a period of twenty-four hours, 
allowing merely a little broth or diluted milk or a little claret in 
water, at the same time feeding the patient by rectum. In order 
to allay the gastric hyperalgesia and the vomiting, cerium oxalate 
in ten grain doses, frequently repeated^ or cocaine, as described else- 
where, or 2 per cent, chloroform water should be given, while 
cold or hot applications, according to the likes of the patient, 
should be applied over the epigastrium. The severe thirst that 
usually appears during the period of food and drink restriction can, 
to some extent, be mitigated by allowing these patients to chew 
gum, to swallow small pieces of ice at frequent intervals, or even 
to smoke a little. 

After this rest cure for the stomach the patient should be put 
for a day or two upon milk and gruels composed of almond meal 
or gluten-flour and then gradually the broad dietary resumed, 
care being taken all the time that the maximum of food is in- 
troduced by rectum in order to maintain general nutrition. 

The more chronic dyspeptic disorders in diabetes call for care- 
ful analysis of the gastric function and for treatment that does not 
materially differ from that described in the Chapter on Diseases 
of the Stomach. 

Catarrh of the bowel is always serious in diabetes. Acute ca- 
tarrh with profuse diarrhea should be attacked most energetically 
in every case; for the interference with food assimilation that re- 
sults, rapidly weakens the patient and not infrequently directly 
precipitates coma. Bismuth subnitrate in doses of fifteen to twen- 
ty grains (1 to 1.3 gm.), with extract of opium one-half grain, 
and tannic acid suppositories containing about three grains (0.2 
gm.) of the drug, should be given at frequent intervals until the 
diarrhea is checked. An attempt should be made to feed the pa- 
tient by mouth as soon as the bowel movements are controlled. 



DISEASES OF METABOLISM 



221 



During the diarrhea brandy and water should be frequently given 
by mouth, in small doses, by preference ice cold, both to support 
and, in a measure, to nourish the patient. 

Fatty diarrhea (steatorrhea) is not uncommon. Here possi- Fatty diarrhea 
bly the involvement of the pancreas and hepatic insufficiency can 
be held responsible for the condition. The fats in the diet should 
be reduced. Sodium carbonate or calcium carbonate, in ten grain 
(0.65 gm.) doses with pancreatin or ox-gall, of each five grains 
(0.3 gm.), should be administered at frequent intervals during 
the day. 

Obstinate constipation is also often a troublesome and a dan- Constipation 
gerous complication. It, too, not infrequently precipitates coma 
if allowed to persist. Here absorption of bowel poisons from stag- 
nation and putrefaction of bowel contents must be accused of de- 
termining the attack of coma. Usually abundant fat-feeding and 
the restriction of carbohydrates suffice to counteract the constipa- 
tion. Saline waters or a lemonade made of 

Glycerin 3 parts, 
Citric acid 5 parts, 
Water 1,000 parts, 

the whole quantity to be administered in divided doses during the 
day, are all useful measures. 

The best medicines to counteract the constipation in diabetes 
are rhubarb and soda mixtures, either mistura rhei et sodae two 
drachms to three ounces (8 to 100 cc.) or the following powder: 

Ehubarb root, 

Sodium bicarbonate, 

Sulphur, precipitated, of each 10 grains (0.6 gm.), 

M. Sig. : To be taken at night, preferably in milk. 

If these measures do not regulate the bowels, then castor oil 
or the compound infusion of senna may be used to advantage. 

Complicating affections about the heart and arteries, the lungs Complications 
(tuberculosis) and the kidneys that arise in the course of diabetes jJ e !Jrt arteries 
must all be treated according to the principles described in other lungs, kidneys 
chapters. It will rarely become necessary to deviate materially 
from the general dietetic schedule on account, of these complica- 
tions. The simple rules that should be occasionally observed have 
been mentioned in the text. If evidence of severe renal disease 
appears^ especially if the cardio-vascular apparatus becomes in- 
volved, then the diabetes must be relegated to secondary impor- 
tance, and the treatment should be chiefly directed towards the 
cardio-renal disorder according to the principles laid down in the 



222 



DISEASES OF METABOLISM 



Obesity and 
gout 



Neuralgias 



Trophic dis- 
orders 



Coma 



Prevention of 
coma 



Treatment of 
the attack 



Section on Nephritis. The complication of diabetes with obesity, 
and diabetes with the uric acid diathesis, are discussed in their 
appropriate places. 

Among the most distressing secondary symptoms of diabetes 
are the neuralgias, especially about the sciatic nerve and the 
brachial plexus ; and a variety of other nervous disorders manifest- 
ing themselves either as sensory or motor disturbances, or, above 
all, as trophic disorders. Among the latter perforating ulcer and 
gangrene, herpes, pemphigus and glossy skin, brittleness of the 
nails, loss of hair and teeth and diabetic neuritis may be men- 
tioned. 

The symptomatic treatment of the neuralgias is rather unsat- 
isfactory, for the ordinary anti-neuralgic remedies rarely suffice 
to control the pain. The best combination of drugs, in my experi- 
ence, is quinine and opium, given as follows: 

Quinine sulphate, 10 grains (0.65 gm.) 

Extract of opium, % grain (0.0015 gm.) 

M*. Sig. In a capsule repeated three or four 
times a day. 

Antipyrin, in five grain (0.35 gm.) amounts, is also occasion- 
ally of service, especially as it seems to exercise some effect upon 
the glycosuria. Generally speaking, the majority of the nervous 
disorders yield spontaneously if the hyperglycemia can be re- 
duced, so that attention should chiefly be directed towards the 
treatment of the underlying diabetic disorder. 

. The administration of alkalies throughout the course of dia- 
betes as a prophylactic measure against coma has already been 
mentioned. With the appearance of the first signs of coma, espe- 
cially in cases that have been living for some time upon a rigid 
meat-fat diet, some carbohydrate food should at once be admin- 
istered. I have even occasionally practised the intravenous in- 
jection of levulose, a sugar that some diabetics can burn with 
facility, and I can testify from personal experience to an oc- 
casional good symptomatic result from this practice. Inversely, 
coma may sometimes be averted in a patient living upon a very 
liberal diet by great restriction of the carbohydrate food. The 
sudden withdrawal of carbohydrates from the diet, i. e., placing 
the patients at once upon a meat-fat diet is always dangerous; 
for coma has many times been produced by this course. We are 
unable to explain these peculiar, apparently paradoxical phenom- 
ena, but empirically they are certainly true. 

In fully developed coma the patients are usually semi-conscious 
or comatose; there is generally severe vomiting and other gastro- 



DISEASES OF METABOLISM 



223 



intestinal disturbance, so that dietetic rules, even if they would 
lead to any result, could not be carried out. The treatment here 
lies along different lines. Diabetic coma is always an exceedingly 
dangerous and usually a fatal complication, and almost all the 
measures that we can employ unfortunately merely fulfill the 
purpose of partially reviving the patient and postponing the fatal 
issue for a short time. The patient in the first stages of diabetic 
coma should be put to bed and forced if possible to drink milk or 
large quantities of lemonade. At the same time the action of the 
heart should be supported, either by alcohol, which acts also as a 
food, given by mouth, or camphor (10 per cent, solution in oil or 
ether), or ether injected subcutaneously. Oxygen should be ad- 
ministered, for it often relieves the dyspnea. The most impor- 
tant remedy to administer, however, is sodium bicarbonate. It 
should be given by mouth, by rectum, by hypodermoclysis and in- 
travenously, in 3 to 5 per cent, solution in normal salt. However 
large the dose of soda the urine rarely loses its acidity, and where- 
as 5 gm. per diem normally always suffice to render the urine alka- 
line, over 100 gm. may not do it in coma. A diabetic patient in 
coma cannot get too much soda. 

This is one of the most distressing and dangerous complications Gangrene 
of diabetes. When it is once fully established amputation of the 
affected member becomes necessary. Most surgeons recommend 
dressing the gangrenous extremity with a moist boric acid solution 
and awaiting the appearance of the line of demarcation before 
performing amputation. An excellent preliminary plan is immer- 
sion of the gangrenous area in a 1 : 2,000 bichloride solution for 
half an hour two or three times a day. In a diabetic gangrene, 
particularly, the amputation should be performed high up in the 
region of healthy arteries. With the appearance of gangrene the 
diet should never remain altogether carbohydrate-free. It is al- 
ways better to allow from 50 to 100 gm. of white bread or its 
equivalent. Occasionally prophylactic treatment should be insti- 
tuted, especially in old people or in alcoholics, or in individuals 
with marked arterio-sclerosis, who complain of certain premonitory 
signs like continuous pain, tingling or hyperesthesia in some ex- 
tremity. Here everything should be done to promote the venous 
back-flow from the affected member. Hot foot-baths and massage 
should be energetically instituted, while, at the same time every 
effort should be put forward to reduce the glycosuria. 



PROPHYLACTIC AND CAUSAL TREATMENT IN DIABETES. 

A few words may be added in regard to prophylactic and causal Hereditary 
treatment in diabetes. In many cases of diabetes an hereditary 
element is very apparent. The disease runs in families and if 



224 



DISEASES OF METABOLISM 



Test for ali- 
mentary gly- 
cosuria 



Causal treat- 
ment 



Neurotic dia- 
betes 



diabetes itself does not appear in the ancestry of a diabetic, then 
one will often discover one or several members of the family who 
suffer from obesity or gout. If several members of a family are 
diabetic, or if there is a tendency to obesity or gout, then all the 
members of such a family should be warned against over-indul- 
gence in carbohydrate foods. Their urine should be examined at 
intervals of at least six months for the appearance of sugar. 
Particular care should be exercised in this direction in individ- 
uals of such families who are obese or are rapidly becoming obese, 
for in them frequently the deposit of fat in the tissues may almost 
be considered a precursor of diabetes ; the sugar in such cases, one 
must assume, being converted into fat and deposited in the tissues 
instead of being wasted as sugar in the urine. 

In order to make quite sure that a tendency to diabetes is 
not developing in individuals with an hereditary tendency, the 
test for the presence or absence of an alimentary glycosuria may to 
advantage be made from time to time. This is carried out by 
giving such subjects 100 to 150 grammes of dextrose at one time on 
an empty stomach. In a normal subject no sugar should appear 
in the urine after this test; if the tolerance for sugar is reduced, 
then glycosuria will appear. This warning should never be neg- 
lected and as a prophylactic measure the carbohydrate foods should 
be somewhat restricted and the use of sugar and sweets tempor- 
arily reduced to a minimum. At the same time such individuals 
should be instructed to indulge in abundant muscular exercise and 
to live as much in the fresh air as possible. Very obese subjects 
should be submitted to a careful reduction cure, as described in the 
next section. 

Cases of this kind, in which diabetes is suspected from the 
family history and in which the test for alimentary glycosuria gives 
a positive reaction, are fortunate exceptions; fortunate, because 
at this early stage proper treatment generally quickly restores nor- 
mal conditions and prevents the development of true diabetes. As 
a rule diabetes develops without warning or sugar is discovered by 
chance during a life insurance examination or in the course of 
some ailment that calls for an analysis of the urine, so that an 
opportunity for prophylactic treatment is unfortunately rarely of- 
fered. 

Causal treatment is not very satisfactory in view of our ignor- 
ance of the precise nature of the disease and on account of the 
manifold character of the causes that determine its onset. There 
are certain cases of diabetes that develop on the basis of a neuras- 
thenic tendency. This form, it appears to me, is particularly com- 
mon among Jews. The sugar excretion of these cases is frequently 
increased by worry or emotional strain, and decreased by joyful 



DISEASES OF METABOLISM 



225 



game nervous 
diseases 



emotions or success and happiness. Here causal treatment must 
clearly be directed towards the underlying neurotic taint, with the 
aid of certain nerve tonics and sedatives (see Medicamentous 
Treatment) and those other means that are described in full in 
the Chapter on Gastric Neuroses. 

In organic disorders of the nervous system, that is, in tumors, Diabetes in or- 
bemorrhagic foci, cysts or other lesions in the region of the "gly- 
cosuric center" in the medulla, and possibly in other areas of the 
brain and cord, the prognosis is dependent altogether upon the 
nature of the underlying lesion; and treatment is successful only 
in so far as it can remove the mechanical cause producing the dis- 
order. 

Provided the lesion in the nervous system is syphilitic, or if Syphilis 
there is a suspicion of syphilitic interstitial pancreatitis or he- 
patitis, then energetic antiluetic treatment, as discussed in another 
portion, is occasionally fraught with success. Inasmuch as syphilis 
of the nervous system, the pancreas and the liver, as well as arte- 
rial degeneration due to syphilis, may all occasionally produce 
diabetes (the latter by producing secondary nutritional, i. e., de- 
generative, changes in the pancreas, medulla, etc.), every case of 
diabetes giving a syphilitic history should be granted the full 
benefit of long continued and persistent anti-syphilitic medication, 
The results obtained from such treatment are frequently exceed- 
ingly gratifying. 



OBESITY. 



The reduction of obesity is an important therapeutic task, not Importance of 
so much when considered in the light merely of a tribute to the obesity S 
vanity of the afflicted, but chiefly when regarded as a necessity in 
order to remove an over-growth of adipose tissue leading to dis- 
agreeable and dangerous complications about important organs. It 
will often be found that these complications only disappear when 
the fat is reduced. We see here similar conditions as in diabetes, 
for there, too, many of the complications rapidly disappear when 
the sugar is reduced. Whereas in diabetes the causes that deter- 
mine these complications are chemical, in obesity they are me- 
chanical in character. 

The organs most frequently and most seriously affected in 
obesity are the heart and arteries, the bronchi, the digestive ap- 
paratus, the nervous system and the skin. 

Upon the heart is always thrown an enormous amount of ex- Complications 
cessive labor. First, because the body is heavier and locomotion heart 
requires more labor. Second, because a much larger vascular area 



226 



DISEASES OF METABOLISM 



Fatty degener- 
ation of the 
heart and 
arteries 



Complications 
about the re- 
spiratory ap- 
paratus 



Dyspnea 

Chronic bron- 
chitis 



than in a normal subject must be supplied, owing to the intricate 
labyrinth of new blood vessels that forms in the adipose tissue. 
Third, because the development of fat in the mediastinum and 
around and within the pericardium exercises mechanical pressure 
upon the heart and hence interferes with its action. Fourth, be- 
cause fatty degeneration of the vessel walls very often occurs, with 
loss of elasticit}' and consequently an increased strain upon the 
heart muscle. Fifth, because owing to the development of ab- 
dominal fat the excursions of the diaphragm are seriously inter- 
fered with and there is a general contraction of the thoracic space 
with a reduction of its suction action, and hence a general em- 
barrassment of the venous circulation. Lastly, because either as a 
result of all this over-strain^ or as a part phenomenon of the gen- 
eral obesity, fatty infiltration or fatty degeneration of the heart 
muscle itself occurs. 

As a matter of fact the affliction of the heart is probably the 
most serious consequence of obesity; for most obese subjects suffer 
from cardiopathy and die from heart failure. If, moreover, they 
should become affected with some intercurrent infectious disease, 
as pneumonia, typhoid fever, tuberculosis, etc., then the resisting 
powers of the heart are so slight that death commonly occurs from 
failure of the organ. 

The involvement of the heart in obesity leads to the closing of 
a vicious circle; for the weak heart action produces an inadequate 
blood supply to various portions of the body with insufficient nutri- 
tion of muscular tissues and general lassitude, all factors that in 
predisposed subjects favor the development of obesity ; on the other 
hand, as soon as obesity appears, it in its turn reacts unfavorably 
upon the heart. 

About the respiratory apparatus serious disorders are also very 
common. The fat in the mediastinum and the increased weight of 
the chest walls, the impediment to the downward excursions of the 
diaphragm that is created by the over-growth of abdominal fat, all 
seriously interfere with the freedom of the lungs and the ventila- 
tion of the thorax. As a result rapid breathing, especially on ex- 
ertion, dyspnea, and above all, chronic bronchial catarrh are very 
common in obesity. The bronchial catarrh is due in part also to 
the venous stasis that results from the cardiac insufficiency. The 
mucus is, as a rule, very tough and difficulty to expel. The pa- 
tients cough terrifically, usually without much relief^ as expulsion 
of the mucus is rendered hard by the emphysema and the venous 
stasis in the lungs and by the difficulty of expanding the chest as 
a preliminary to the coughing effort. This condition again im- 
poses a severe strain upon the heart, especially the right heart. 
The bronchitis in obesity rarely yields to the ordinary remedies, 



DISEASES OF METABOLISM 



227 



but is promptly bettered if the obesity is reduced, and the condition 
of the heart improves. In obesity there is, therefore, also from this 
source again, danger of pulmonary infections and many of these 
cases succumb to catarrhal pneumonia, and, notably, to tubercu- 
losis. There is a popular prejudice to the effect that obese sub- 
jects are not very susceptible to tuberculosis; if tuberculous infec- 
tion occurs, however, it usually goes very hard with fat patients, 
and they constitute a large proportion of the instances of so-called 
"galloping" consumption. 

The disorders about the digestive apparatus are manifold in 
character. Most of them are due to the venous stasis that re- 
sults either directly from the heart weakness or indirectly from 
portal stasis. The most common intestinal symptoms in obesity are 
hemorrhoids and constipation; both are almost invariably pres- 
ent, the former due either to the portal stasis or to general inter- 
ference with the venous backflow into the abdomen, the latter due 
to the pressure of the fat masses within the abdomen upon the 
bowel, causing interference with their peristaltic action; besides 
there is always much difficulty in voluntarily raising the abdominal 
pressure sufficiently to promote normal defecation. The one-sided 
diet with the elimination of much fat and carbohydrate pabulum 
may also have something to do with constipation in obesity. 

Fatty infiltration of the liver ? combined with stasis and later 
cirrhosis, is not uncommon. Cholelithiasis and dislocation of the 
liver are not common during the stage of obesity, but frequently 
follow rapid reduction cures, owing to the fact that the support 
of the abdominal fat is rapidly withdrawn, and malposition of 
the liver and bending or knuckling of the gall-ducts is produced. 

About the skin a variety of irritative disorders, complicated 
by secondary infections, are frequent. They are due both to the 
friction of abnormally enlarged adjacent parts of the body and to 
the profuse sweating that most obese subjects are afflicted with. 
The sweating is attributable presumably to an effort on the part 
of the organism to get rid of surface heat by water evaporation 
from the skin, especially as normal radiation is interfered with 
on account of the thick adipose layer that conducts heat so badly. 
Obese subjects frequently suffer from intertrigo, eczema, furun- 
culosis, carbuncles and sudamina; besides the skin often becomes 
torn in its lower layers, leading to the formation of strise, while 
at the same time capillary hemorrhages, venous ectases, are fre- 
quent and varicose veins in various parts of the body make their 
appearance. 

About the nervous system, finally, a great variety of func- 
tional disorders, many of them of a neurasthenic type, are common. 
Most of them are due to the inadequate blood supply to the brain 



Digestive dis- 
orders 



Hemorrhoids 
Constipation 



Fatty infiltra- 
tion of the 
liver 

Cirrhosis 
hepatis 



Skin affec- 
tions 



Nervous dis- 
orders 



228 



DISEASES OF METABOLISM 



Phlegmatic 
temperament 



Obesity and 
joint affections 



The three 
forms of 
obesity 



Diet and ex- 
ercise 



that results from the heart weakness. Apathy and a phlegmatic 
temperament are notoriously common in obesity. These psychic 
attributes, combined with what is popularly interpreted as a good- 
natured disposition, are presumably a result of the bulk of the 
individual; for ? with the difficulty of moving about freely, and an 
inability to speedily carry the dictates even of an energetic will 
into rapid execution, habits of listlessness, laziness and indifference 
are easily engendered, so that after a time the bodily condition 
becomes reflected in the temperament. 

More serious manifestations about the nervous system are apo- 
plexies, especially in patients with a weak heart and arterio- 
sclerotic arteries, who are suffering from such conditions as bron- 
chitis, constipation, etc., which call for violent straining efforts. 

I have summarized the various complicating disorders in obes- 
ity somewhat at length, because from a therapeutic standpoint it 
is exceedingly important to recognize the etiologic role of obesity 
in these various states. Treatment directed towards them sympto- 
matically is usually futile and intelligent therapeutic effort must 
concern itself chiefly with removing the underlying cause, name- 
ly, the obesity. I will have occasion to refer to this form of treat- 
ment again in the different sections when discussing diseases of 
the heart and bronchi, of the bowel and the liver. 

The importance of reducing obesity in a variety of chronic 
joint disorders may finally also be mentioned; for here the re- 
duction of the bulk of the patient by relieving the joints of the 
labor of supporting a large mass acts in the same way as a me- 
chanical support. Thus the reduction of obesity is a particularly 
grateful procedure in chronic rheumatic and gouty forms of ar- 
thritis. 

As in diabetes, one can conveniently distinguish three degrees 
of obesity that have been aptly characterized by a German writer 
as the enviable, the comical and the pitiable stages. The first pre- 
senting itself as a pleasing rotundity; the second, as a jovial em- 
bonpoint of the Falstaff type ; the third as a sad, unwieldy, and to 
our Caucasian tastes, disgusting deformity. Each of these three 
forms requires particular treatment. In the first form no attempt 
need be made to reduce the amount of fat but every effort should 
be put forward to prevent its further development, particularly if 
premonitory signs of complications about the thoracic or abdom- 
inal organs begin to make their appearance. In the second and 
third forms, however, it becomes necessary to institute more or 
less energetic restrictions with the object in view of causing a 
loss of fat. 

The methods at our disposal for accomplishing this purpose 
are chiefly dietetic. Second in importance is the regulation of 



DISEASES OF METABOLISM 229 

the muscular exercise. These two means, singly or combined, 
usually suffice to accomplish the desired purpose, for with a de- 
crease of the intake of fat-forming pabulum, and an increase of 
its destruction by exercise, the fat content of the body must needs 
dwindle. These measures may to advantage be enforced by cer- 
tain hydro-therapeutic and medicinal means, the latter finding 
their chief sphere of application, however, in the symptomatic 
treatment of the complications of obesity. 

THE DIETETIC TREATMENT OF OBESITY. 

Physicians until recently, and the laity to this day, have di- T he , quality of 
rected their attention chiefly to the quality or the preparation of j ts mo de of 
the food in reducing obesity. Certain articles were said to form preparation 
fat and others not. This idea is erroneous. Broadly speaking, 
carbohydrate and fat foods should be reduced, and not the albumens. 
This rule is to be observed not because albumen "forms" less fat 
than carbohydrates or fats, but because the reduction of the albu- 
men below certain normal average requirements, as will be ex- 
plained below, is a dangerous and precarious procedure, whereas 
the fats and carbohydrates can be much reduced without detriment 
to the individual. 

One may say, axiomatically (but with certain restrictions that T . he , Quantity 
need not be discussed in this volume) that any article of food 
can form fat according to its caloric value, that if more calories 
are introduced either in the form of albumens or of fats or of car- 
bohydrates, than are required to maintain normal nutritive equi- 
librium, then fat will be deposited in the tissues; and if less are 
introduced, that then the organism will promptly attack first its 
fat reserve to make up the caloric deficit. 

THE SCIENCE OF REDUCTION CURES. 

The initial procedure in instituting a reduction cure should 
be to determine the normal caloric requirement of the individual, 
assuming that he were not obese. This can be done by consult- 
ing the following table on which will be found the normal aver- 
age weight for individuals of a certain height, both men and 
women: (Quetelet.) 

Weight, Women, Weight, 
(kilo- Height, (kilo- 
grammes ) . * * (in meters ) . grammes ) . 
3.2 0.49 2.91 
9.45 0.69 8.79 
11.34 0.78 10.67 

*1 meter = 39.37 inches, or 1 yard 3 1-3 inches (English). 
**1 kilogramme = 2 lb. 3 oz. 2 dr. (avoirdupois). 





Men, 


Age, 


Height, 


Years. 


(in meters). 





0.5 


1 


0.7 


2 


0.77 



230 



DISEASES OF METABOLISM 



Age, 
Years. 
3 


Men, 
Height, 
(in meters). 
0.86 


Weight, 
(kilo- 
grammes). 
12.47 


Women, 
Height. 

0.85 


Weight, 
(kilo- 
grammes) 
11.79 


4 


0.92 


14.23 


0.92 


13.00 


5 


0.99 


15.77 


0.98 


14.36 


6 


1.05 


17.24 


1.10 


16.01 


7 


1.11 


19.10 


1.15 


17.54 


8 


1.16 


20.76 


1.18 


19.08 


9 


1.22 


22.65 


1.19 


21.36 


10 


1.28 


24.52 


1.25 


23.52 


11 


1.33 


27.1 


1.30 


25.7 


12 


1.39 


29.8 


1.35 


29.8 


13 


1.44 


34.4 


1.40 


32.9 


14 


1.49 


38.8 


1.45 


36.7 


15 


1.55 


43.6 


1.49 


40.4 


16 


1.59 


49.7 


1.54 


43.6 


17 


1.63 


52.9 


1.56 


47.3 


18 


1.66 


57.9 


1.56 


51.0 


20 


1.67 


60.1 


1.57 


52.3 


25 


1.68 


62.9 


1.58 


53.3 


30 


1.68 


63.7 


1.58 


54.3 


40 


1.68 


63.7 


1.58 


55.2 


50 


1.67 


63.5 


1.53 


56.2 


60 


1.63 


62.9 


1.52 


54.3 


70 


1.62 


59.5 


1.52 


51.3 


Simplest form gy 
of reduction . 
cure caloric 


multiplying this 
requirement can 


weight by 30 to 35 the approximate daih 
be obtained, for, as shown on page — , 



Three degrees 
of reduction 
cures 



a 

normal subject requires from 30 to 35 calories per kilo a day to 
maintain adequate nutrition. Assuming that the patient were 
1.67 meters tall, then according to the table he should weigh about 
61 kilos and require 61 X 30 to 35 = 1,830 to 2,135 calories a 
day. 

The diet should now be arranged in such a way, with the aid of 
the tables on page — , that this number of calories is furnished, 
not more and not less. This constitutes the mildest form of un- 
derfeeding, for here the caloric intake is insufficient only relatively, 
i. e., as compared to the abnormal bulk of the patient. If now 
the patient does not lose weight on a diet containing the full normal 
caloric requirement, then it becomes necessary to reduce the caloric 
intake still further. 

It is convenient to follow the plan of von Noorden and to ar- 
range three degrees of reduction cures. In the first degree the 
caloric requirements are reduced only to four-fifths of the normal, 



DISEASES OF METABOLISM 



231 



in the second to three-fifths and in the third to two-fifths. Calcu- 
lating this for an individual, e. g., requiring 2,500 calories as the 
normal, the first degree calls for the administration of foods pos- 
sessing a caloric value of about four-fifths of 2,500 or 2,000, the 
second of three-fifths of 2,500, or about 1,500, and the third of 
about two-fifths of 2,500, or about 1,000 calories. The popular 
diets of Banting, Oertel, Epstein, Hirschfeldt and others possess 
a caloric value lying between 1,100 and 1,600 only; they are con- 
sequently reduction cures of the third degree and, as will be pres- 
ently shown, usually far more severe than is safe or necessary. 

The rapidity with which fat is lost in these three degrees of re- 
duction cures varies. In the first degree the loss is usually very 
slow, the patients rarely losing more than two or three pounds a 
month; and even this slight reduction can only be accomplished 
if they indulge at the same time in considerable physical exercise. 
The four-fifths diet is useful chiefly in preventing the further in- 
crease of fat in subjects who are showing a tendency to obesity. It 
is eminently suitable for continued use and does not require any 
great sacrifice on the part of the patient. It is hardly ever neces- 
sary to calculate the caloric value carefully in this light form, all 
one has to do is to alloAV less meats, to reduce the amount of fat 
and starchy and sweet foods somewhat, to restrict or forbid alcoholic 
beverages, to give "filling" foods of small caloric value in abund- 
ance, to restrict the liquid intake to one or one and one-fourth 
litres of fluid a day, and to order abundant physical exercise. 

The second degree is also particularly useful for continued 
use. It should be adopted, first, for very strong and very fat sub- 
jects who want to get rid of surplus fat and can safely indulge in 
very active physical exercise; second, for individuals who not only 
are fat but in whom complicating disorders about the heart, ar- 
teries, bronchi or digestive apparatus render it impossible to "work 
off" fat by exercise; here the necessary reduction of the fat must 
be brought about, in the beginning and until the complications im- 
prove or disappear, by dietetic restrictions alone; third, for fat 
individuals who cannot at once tolerate a third degree reduction 
cure without developing alarming symptoms of weakness, par- 
ticularly about the circulatory and muscular apparatus. In the lat- 
ter class of cases the three-fifths reduction cure is used as a tran- 
sition diet to the third degree and is intended to gradually accus- 
tom the patients to restrictions of a more severe order to be in- 
stituted as soon as some fat is lost and the complications have 
improved. This second degree, too, leads only to relatively slight 
and slow losses of fat, more than six to ten pounds rarely being 
sacrificed a month. 



Banting, Oer- 
tel, Epstein, 
JHirschfeldt 



cures 



The first 
degree 



The second 
degree 



232 



DISEASES OF METABOLISM 



The third 
degree 



Danger of re- 
duction cures 
in young and 
old subjects 



The third degree, finally, is a rapid reduction cure. It must be 
carefully supervised and is best carried out in an institution. Here 
we frequently find that the loss of fat is rapid in proportion to the 
obesity of the individual, showing that it is the surplus adipose tis- 
sue that is being sacrificed and not the albumen of the body. Com- 
bined with systematic exercise and drink restriction (see below) as 
much as thirty pounds a month can be lost with safety. A reduc- 
tion cure of the third degree should never be carried out for in- 
definite periods, and six weeks is the longest time during which 
this serious restriction of the patient's nourishment should be al- 
lowed. In many cases the intermittent plan will have to be adopted, 
i. e., the patients are placed for four to six weeks upon 1he rigid 
plan, then for a month or two upon the second degree, and then 
back again to the rigid diet until the desired loss of flesh has been 
produced. 

It will be seen that here very similar principles are adopted as 
in the reduction of diabetic glycosuria, where, too, three degrees of 
diabetic diet can be conveniently arranged. While it is true that 
energetic starvation often rapidly leads to a loss of weight greater 
than that which can be accomplished by more gradual and more 
moderate means, such rapid reduction cures, as typified for in- 
stance by the Banting system, which is so popular among the laity, 
are rarely without serious danger to the various organs that are 
commonly involved in advanced degrees of obesity; nor are the 
results, broadly speaking, permanent. 

In very young people and in very old people rapid reduction 
cures should be altogether eschewed ; for in children and in adoles- 
cent subjects irreparable damage is often done, growth stunted 
and serious complications engendered; whereas, in old people, the 
results are usually very unsatisfactory and never without danger, 
while the effects at best are exceedingly transitory. 



The kind of 
food 



Importance 
of protecting 
the tissue al- 
bumens 



THE ART OF REDUCTION CURES. 

The kind of food that should be allowed in instituting any re- 
duction cure, and its mode of preparation, has been the subject of 
much controversy for many years. The greatest care should be 
exercised not to attack the albumen content of the body; hence it 
is important to give a certain amount of albuminous food to all 
cases in order that the patients may not be forced to consume the 
albumen of their proper tissues. As the known minimum neces- 
sary for maintaining adequate nutrition lies somewhere between 
60 and 80 grammes a day, this amount at least should be invari- 
ably supplied. This corresponds to 400 to 600 grammes of lean 
meat (see below). No difficulty should be experienced in meeting 
this requirement. Notwithstanding the claims of some doctrinaires, 



DISEASES OE METABOLISM 



233 



Restriction of 
fats and car- 
bohydrates 



excessive meat-feeding is not only unnecessary, but may be directly 
harmful in instituting reduction cures. A great deal will depend 
upon the tastes and the previous habits of the patients. If they 
have not been excessive meat-eaters, there is no reason why they 
should be forced to eat much meat. If they have been abund- 
ant meat-eaters, they may safely continue meat-eating, provided 
the intake is not so large that the total caloric value of the food 
is increased above the prescribed and calculated limit. 

The next question to decide is whether the carbohydrates or the 
fats are to be chiefly restricted. Here, again, a very virulent con- 
troversy has been going on for many decades. This is not the place 
to enter into a discussion of the merits or demerits of the different 
theories advanced. From a practical standpoint it is best to re- 
duce the fats and to give relatively large quantities of such carbo- 
hydrate foods as possess bulk; for the latter, as a rule, incorporate 
a small caloric value, while, at the same time, fully satisfying the 
patient. The idea that fat forms fat in the body more than car- 
bohydrate has been shown to be erroneous; as a matter of fact, 
carbohydrates seem to be more rapidly deposited as reserve fat in 
the tissues than the fat that is eaten. 

To summarize, therefore, the diet in reduction cures should be Summary 
arranged in such a way that the individual receives an amount of 
albuminous food incorporating at least 60 to 80 grammes of albu- 
men. This is necessary in order to maintain nitrogen equilibrium 
and to protect the tissue albumen. The remaining number of cal- 
ories that are to be supplied, according to the principles discussed 
above, may be vicariously furnished, either in the form of fats or 
carbohydrates. Of the two the carbohydrates, however, especially 
if they are voluminous, should be given the preference. 

The distribution of the meals is sometimes of importance. The 
best plan is to give three meals during the day and, in addition, 
two or three small meals between, the latter preferably consisting 
of articles like bouillon, coffee or a little fruit, that possess a small 
caloric value. They serve the purpose of keeping the patient com- 
fortable, avoiding disagreeable sensations of weakness and gastric 
emptiness, and, at the same time, preventing the patient from 
becoming too ravenously hungry at meal times and consequently 
from over-eating. 

One other important principle must be observed in the feed- 
ing, viz., the liquid intake should be restricted. Nothing is easier 
than to rapidly reduce the weight of an obese subject by restricting 
the liquid intake to a minimum. This loss of weight becomes par- 
ticularly apparent during the first four or five days of the cure. It 
is due, in the first place, to a direct loss of water from the tissues ; 
in the second place, to the fact that an individual drinking very 



Distribution 
meals 



of 



Restriction 
liquids 



of 



234 



DISEASES OF METABOLISM 



Suggestion 
effect 



Alcohol 



Special ar- 
ticles of diet 



Meats 



Delicacies 



little water does not eat as much as one taking a normal amount 
of liquid. The restriction, therefore, in the beginning is a useful 
procedure, more for psychic than for physiologic reasons; for the 
patients when they notice how rapidly they are losing flesh, ac- 
quire that confidence in the method that is so important if they 
are to carry out the more or less disagreeable and stringent orders 
that must be given. No permanent effects, however, are obtained 
from this restriction of liquids, and the patients regain their weight 
as quickly as they lost it, as soon, namely, as they begin to increase 
water-drinking. Nevertheless, even in cases in which the restric- 
tions are to be continued for a long time, a reduction of the total 
liquid intake to about one to one and one-half litres in the twenty- 
four hours is a useful adjuvant. It renders it easier for the pa- 
tients to live up to their restrictions and it is also beneficial in 
advanced cases of obesity with complications, because it spares the 
heart and kidneys. In cases, finally, that suffer from excessive 
sweating, the restriction of liquids is also a very useful procedure 
to remove this disagreeable symptom. 

Alcohol may be administered to obese subjects, provided the cal- 
oric value of each gramme of alcohol (1 gramme = 7 calories) is 
carefully included in the calculation. It should be allowed particu- 
larly in cases that have been accustomed to a little alcohol all their 
lives; for here withdrawal of alcohol is not only an unnecessary 
hardship, but may even constitute a source of danger, especially if 
a weakened heart is suddenly robbed of its usual stimulus. 

A few words may not be amiss in regard to certain special arti- 
cles of food that are of particular value in the dietetic treatment of 
obesity. 

In selecting meat for obese subjects lean varieties should be 
given the preference. Lean meat contains about 20 per cent, of 
albumen and 1.5 to 2.0 per cent, of fat, so that 100 grammes of 
lean meat, weighed raw, furnish about 100 calories. It is neces- 
sary, of course that the meat should be prepared in a very simple 
way, i. e., that it should be either stewed, roasted or broiled. All 
meats that are prepared by frying, or that are served as ragouts 
or with bread crumbs, sauces and gravies, of course contain incal- 
culable amounts of fat, so that their caloric value may assume very 
large proportions. It is always best, therefore, to forbid the use 
of any but lean meats, plainly prepared. 

Among the animal foods that an obese subject can eat with 
impunity are a number of delicacies that are taken only in small 
quantities and, on account of their flavor, are very agreeable ad- 



DISEASES OP METABOLISM 235 

ditions to the diet; tlms according to a table published by von Noor- 
den, 100 calories are contained in: 

45 grammes of caviar. 

40 grammes of sardines. 
100 grammes of boiled lobster. 
160 grammes of crab meat. 
120 grammes of oysters (equal to about 14 to 
18 oysters of medium size). 

25 grammes of pate de foie gra,s. 

Cheese also serves a useful purpose; for taken even in very Cheese 
small quantities it is very filling. Thus Swiss cheese, American 
cheese, Cheddar and Chester cheese contain about 28 per cent, of 
albumen, 30 per cent, of fat and 2 per cent, of carbohydrate, and 
25 grammes of these cheeses furnish about 100 calories. 

Milk is a very useful addition to the bill of fare,, provided its Milk 
caloric value and the water it contains are included in the calcu- 
lation. 100 cc. of milk furnish about 60 calories. This amount 
can safely be allowed with tea and coffee. Buttermilk is still more Buttermilk 
useful; for 100 cc. of this beverage only contain from 40 to 45 
calories, and a whole quart about 250 calories. 

Thin soups and bouillons and beef tea are exceedingly useful Soups 
articles, for their caloric value is practically 0. They are very 
filling, they taste good, and the patient eating a large plate of 
bouillon imagines that he is getting something of value. 

Rich sauces, as stated above, should be absolutely forbidden, Sauces 
because they are made of large quantities of fat, flour, eggs and 
their caloric value can hardly be calculated. Articles made of Articles made 
flour or rice, like noodles and macaroni, puddings, etc., should not of flour 
be allowed at all in the strict reduction cures. In the first and 
second degrees, however, small quantities may be permitted as a 
relish. If they are given, each tablespoonful of these articles 
should be figured as representing about 30 calories. 

Potatoes are also permitted, provided they are given in small Potatoes 
quantities and are either boiled or baked or mashed and served 
without butter. One hundred grammes of potatoes prepared in 
this way contain about 1.5 per cent, of albumen and 18.5 per cent, 
of carbohydrate, and possess a nutritive value of approximately 80 
calories. 

Among the vegetables those varieties that grow underground Miscellaneous 
as well as those that grow in pods should be forbidden or restricted, ve S etables 
because they contain very large and varying amounts of carbo- 
hydrates. If they are permitted at all in the lighter reduction 
cures their caloric value should be carefully determined. All the 
other vegetables are exceedingly useful articles of diet in obesity, 



236 



DISEASES OE METABOLISM 



Preparation of 
vegetables 



Fruit 



Bread 



Mineral 

waters 



T> A „ ort treat . 

ment 



for they possess a very small caloric value in proportion to their 
bulk and consequently fill the stomach and rapidly produce a 
sense of satiety ; incidentally they act favorably upon the function 
of the bowel. They should be served only boiled in salt water, 
without the addition of cream, butter, flour, etc. If flour or fats 
are used in preparing vegetable dishes the amounts of these in- 
gredients should be carefully weighed and their caloric value con- 
sidered. 

Fruits of all kinds, with the exception of bananas, sweet grapes, 
figs, dates, raisins, are permitted without reserve ; they, too, are very 
filling and act well upon the digestive apparatus and constitute a 
great relish without, at the same time, possessing a high caloric 
value. About 100 calories are contained in from 220 to 250 
grammes of fruit. 

The use of bread is permitted in obesity, only, however, if the 
bread is carefully weighed and its caloric value considered. Here 
the same rules obtain as in the feeding of bread to diabetics, i. e., 
those varieties that are made of vegetable albumen (gluten breads, 
aleuronat bread, etc.), are particularly useful if they are baked so 
as to become fluffy and voluminous, for they, too, are filling with- 
out possessing a very large caloric value. I have already shown 
how their caloric value is to be calculated. 

A great many mineral waters enjoy deserved popularity in the 
treatment of obesity, notably, the waters of Kissingen, Vichy, 
Homburg, Carlsbad and Marienbad. It is a futile task, however, 
to attempt the reduction of obesity by the use of these waters alone. 
It is possible, of course, by producing profuse watery diarrhea with 
the aid of these waters to cause a considerable loss of water from 
the tissues and hence a reduction in the weight of the patient. This 
practice is of some use for psychologic reasons, because the rapid 
loss of weight in the beginning of the treatment makes a great im- 
pression upon the patients and renders them more willing to fol- 
low directions later on. The indiscriminate use of mineral waters 
is, however, to be condemned; for if the diarrhea is allowed to per- 
sist too long the effect is without doubt weakening, and this prac- 
tice, moreover, reacts unfavorably upon the blood pressure and the 
heart, especially in obesity. 

These patients do very well, as a rule, in resorts in which 
these waters are taken, but the effects are to be attributed only in 
a very small part to the drinking of the particular water, and 
much more to the careful dietetic regulations that are usually 
carried out in these watering places, and, above all, to the in- 
creased muscular exercise that these patients willingly undergo in 
a resort. 



DISEASES OF METABOLISM 



237 



Terrain cure 
in Nauheim 



This element of muscular exercise is second in importance only Muscular ex- 

excise 

to the regulation of the diet in obesity. It can readily be cal- 
culated how a definite amount of muscular exercise causes the loss 
of a definite amount of fat. Oertel, who has studied, more than 
anybody else, the effect of graduated exercise, especially grad- 
uated hill-climbing, upon obesity and the action of the heart, based 
his original recommendations upon definite calculations.* 

In Xauheim and certain other watering places the Oertel- 
Terrain cure is given by instructing the patients to slowly climb 
a series of paths that are elevated at an angle of from to 20 de- 
grees: at the same time, certain other factors are carefully con- 
sidered, and as the heart's action improves and the fat is lost, more 
exercise is allowed each day. In this way it is possible to care- 
fully grade the exercises and remarkably good results are obtained 
from this practice. 

Other useful exercises besides walking on a level or hill-climb- 
ing ? are bicycle riding, rowing and a number of light out-of-door 
games. Eowing is especially useful, for the amount of exercise 
can be carefully regulated while, at the same time, full expansion 
of the lungs with improved oxygenation is promoted. In winter 
rowing machines fulfill the same useful purpose. Horse-back riding 
enjoys very good repute as a means of reducing obesity; this repu- 
tation, as a German writer states, is deserved as far as the horse 
is concerned, but not the rider; horse-back riding stimulates the 
appetite more than any other exercise, without leading to any 
reduction of the body fat. 

Massage is of no value whatever in the treatment of obesity. 
Von Xoorden and his pupils have shown by very careful metabolic 
studies that long continued massage of the whole body exercises 
no greater influence upon metabolism than opening and shutting 
one hand energetically a few times. 

Hydro-therapeutic measures are useful for several reasons. Hydrotherapy 
Cold baths, especially when combined with friction, cause a con- 
siderable loss of heat from the surfaces of the body and hence stim- 
ulate the organism to increased heat production with consump- 



Outdoor 
sports 



Horseback 
riding 



Massage 



* Assuming that a man weighing 60 kilogrammes ascends an eleva- 
tion each day of 100 meters, then the labor performed is equal to 60 X 
100 = 6,000 kilogrammeters; as a matter of fact, much more energy is 
expended, for the external labor produced represents only about 30 per 
cent, of the total energy developed; thus such an individual in a day 
develops fully 20,000 kilogrammeters of energy. As 425 kilogrammeters 
of muscle work require 1 calorie, 20,000 kilogrammeters require 47.06 
calories, and this amount of caloric value is furnished by 47.06 -=- 9.3 = 
5.06 of fat. It will be seen, therefore, that such an individual must 
consume 5.06 of body fat to raise his body 100 meters. It is immaterial, 
of course, according to the laws of the conservation of energy, whether 
or not this elevation is reached within a short time or within a long 
time, by a vertical path or by a long series of inclined paths. 



238 



DISEASES OF METABOLISM 



Medicinal 
treatment 



Thyroid 
therapy 



tion of body fat. Hot baths act chiefly on account of their diapho- 
retic action and are synonymous in their effect with any other 
sweating procedure. The condition of the nervous system, of the 
circulatory apparatus and of the bronchi and the skin, must al- 
ways be carefully considered when advising the use of hydro- 
therapeutic means, and- the same contra-indications to their em- 
ployment in obesity exist as in any other case of cardio-vascular, 
renal or respiratory disease. These contra-indications have been 
fully discussed in their appropriate places. 

The medicinal treatment of obesity is of very subordinate im- 
portance. The complications occasionally call for drugs, as de- 
scribed in the chapters on the heart, the arteries, the bronchi, the 
digestive organs, the nervous system. For the reduction of obesity 
only one remedy can be employed, namely, thyroid gland prepara- 
tions. 

The use of thyroid in obesity at one time was very popular^ and 
this remedy has been carefully tested for several years. Its effects 
are always uncertain, some obese subjects reacting to the admin- 
istration of the drug by a rapid, sometimes almost alarming, loss 
of flesh, others not reacting at all. The effect of the drug, more- 
over, is not permanent, for as soon as its use is discontinued the 
patients rapidly regain the lost fat; besides, it is not without 
danger, especially when used indiscriminately by the laity ; for the 
syndrome of thyroidism (see index) manifesting itself in a 
variety of disagreeable symptoms about the nervous system and the 
circulatory apparatus is always to be dreaded. Cases are on record, 
moreover, in which the use of large doses of thyroid extract pro- 
duced glycosuria, and in view of the fact that there is an intimate 
pathogenetic relationship between obesity and diabetes, this is par- 
ticularly to be feared ; for occasionally it has seemed that a true dia- 
betes mellitus was precipitated by the use of thyroid extract. Gen- 
erally speaking, the use of the drug is superfluous, because obesity 
can always be reduced if the dietetic regulations discussed in the 
preceding paragraphs are conscientiously carried out. The one 
real benefit that might occasionally accrue from the use of thyroid 
would be to produce a rapid loss of flesh in the beginning of a re- 
duction cure, and in this way to exercise a strong suggestive effect 
upon the patient, thus giving him confidence in the efficacy of the 
measures employed for his relief; but even this suggestive effect 
can, as shown above, be equally well produced by the restriction of 
water drinking or by sweating without, at the same time, doing the 
patient any harm. 



DISEASES OF METABOLISM 



239 



RHEUMATISM. 



The term rheumatism is a remnant of an ancient nomenclature 
and is loosely employed to designate a great number of morbid 
conditions, many of them related in no way to one another. Used 
originally by the humoral pathologists to indicate the circulation 
of disordered humors, it was later applied to a variety of fleeting 
pains in many parts of the body, i. e., to a symptom. As such 
pains were commonly produced by exposure to cold and dampness, 
many disorders that followed such exposure were called rheumatic, 
so that the term was used in an etiologic sense. As the joints 
were commonly affected in these disorders, the term rheumatism 
was later loosely used to indicate joint affections in general. Final- 
ly, a "rheumatic diathesis" was constructed in which there was said 
to be a special predisposition to articular involvement ("Arthrit- 
ism" of the French). 

From the clinical standpoint, and also from the standpoint of 
etiology, it becomes necessary to exclude as not belonging at all to 
rheumatism : 

First. Acute articular rheumatism, or rheumatic fever, a dis- 
ease that is without doubt infectious in character. This disorder 
will be discussed in the Chapter on Infectious Diseases. 

Second. A variety of articular inflammations that are grouped 
under the unfortunate name of pseudo-rheumatism, that are of 
parasitic origin and due to infection of the joints with certain 
bacteria, or to inflammation of the joint membranes by their 
toxins. To this group belong gonorrhea, pneumococeus, diph- 
theritic, influenza, staphylococcus and tuberculous arthritis, also 
the joint lesions seen in scarlatina and measles. These ? too, will 
be mentioned in the section on the different diseases that produce 
them. 

Third. The acute articular lesions of gout. These are often 
confounded with rheumatic lesions but are not related to them. 
Hence they will be discussed separately in the Chapter on Gout 
and the Uric Acid Diathesis. 

In fact "the words 'rheumatism' and 'rheumatic' are often so 
loosely employed that they have almost forfeited all claim to be 
regarded as scientific terms." (A. E. G-arrod.) Consequently I 
do not feel justified in discussing under the title of rheumatism 
the great array of symptoms involving almost every organ of the 
body, chiefly the nervous system, the peri- and endocardium, the 
pharynx, the tonsils, the eye, the skin and the periosteum that have 
been included under this term, but prefer to discuss the "rheu- 
matic" inflammations affecting these different tissues in the Sec- 
tions devoted to the diseases of the various organs involved. On 



Nomenclature 
and definition 



Rheumatic 
fever 



Pseudo-rheu- 
matism 



Rheumatic 
gout 



Muscular rheu- 
matism 



240 DISEASES OF METABOLISM 

account of the great frequency and clinical importance of rheu- 
matic myalgia, and on account of the popularity of the term "mus- 
cular rheumatism" employed to designate this disorder, a special 
chapter may, however, for practical reasons be given to the treat- 
ment of this affection. 
Chronic rheu- There remain to be discussed separately a number of varieties of 

matism "chronic rheumatism." Some of these are consecutive to acute 

articular lesions, others have an insidious onset and run a chronic, 
usually progressive course. They all have a tendency to involve 
several joints, with their tendons and muscle sheaths at once, and 
to appear symmetrically, although some mono-articular forms are 
known (malum coxa? senilis and pseudo-arthritis vertebra lis). In 
all of them are found anatomic changes about the fibrous tissues and 
synovial membranes, the cartilages of the joints with osteophyte 
formation and osseous atrophy. To be excluded from these forms, 
from the standpoint of anatomic classification, are those varieties 
in which urate deposits are present, i. e. ? that are manifestly due 
to the uratic diathesis; also the syphilitic joint lesions and those 
forms that are due to some primary disorders of the spinal cord 
(spinal arthropathies) : finally, those forms that are due to chronic 
suppuration. 

However interesting and important it may be with respect to 
the etiology, pathological anatomy and diagnosis, to differentiate 
between these manifold forms of chronic rheumatism, from thera- 
peutic considerations it is unnecessary; for the treatment of all 
these varieties, notwithstanding their origin and immaterial 
whether the disease involves the joints, the tendons or the muscle 
sheaths, singly or together, is practically the same. Inasmuch as, 
on the one hand, the same term is often used to designate different 
disorders, and, as on the other hand, many terms are employed by 
different writers synonymously, to designate the same lesions, 1 I 
will not undertake in this volume to bring order out of this chaos,, 
especially as any classification, however refined and accurate it 
might be, would in no way render us more successful in the treat- 
ment of chronic rheumatism. 



(1) The most common and the most popular terms employed to 
designate this large and heterogenous group of morbid entities are 
arthritis or pseudo-arthritis deformans, rheumatoid arthritis and 
chronic articular rheumatism. The following terms, however, are all 
used to designate chronic progressive "rheumatism" of different joints 
not due to acute infections (pseudo-rheumatism and rheumatic fever). 

Goutte Asthenique Primitive (Landre Beauvais, 1800). 

Digitorum Nodi (Heberden, 1804). 

Nodosity of the Joints (Haygarth, 1805). 

Chronic Rheumatism of the Joints (Todd, 1843). 

Arthrite seche (Deville and Broca, 1848 and 1850). 

Rheumatisme Chronique Primitif (Charcot and Vidal, 1853 and 
1855). 



DISEASES OF METABOLISM 



241 



It is my intention, therefore, in the following pages, under the 
heading of "Chronic Rheumatism/" to discuss together the treat- 
ment of chronic articular, tendinous and muscular lesions that are 
either consecutive to any of the acute forms of arthritis, or that 
are due to trophic changes (spinal lesions), or that are of un- 
known etiology and run a chronic course. I am fully aware of the 
fact that this procedure must appear inexact, but I see myself re- 
gretfully forced into this necessity by reasons of practical ex- 
pediency, otherwise endless reiteration would be necessary. We 
can only hope that before long more light may be thrown into 
this obscure resrion. 



MUSCULAR RHEUMATISM. 

Muscular rheumatism or myalgia (lumbago, pleurodynia, torti- 
collis, etc.) is in all probability a neuralgia of the sensory nerves 
of the muscles involved and not an affection of the proper muscle 
structures. The term rheumatism, as explained in previous para- 
graphs, is a misnomer. Uric acid has nothing whatsoever to do 
with so-called muscular rheumatism, popular prejudices to this 
effect to the contrary notwithstanding. In view of our ignorance 
of the real nature of myalgia and of its exact causes, treatment 
can, of necessity, be only symptomatic. 

As the disorder generally follows exposure to wet and cold, the 
same rules in regard to clothing and the general hygiene of the 
patient should be observed that are mentioned in detail under 
Rhinitis and Anemia. 

An attack of muscular rheumatism can occasionally be abort- 
ed. Upon the appearance of the pain the patient should take 
a Turkish bath, or a hot bath of 100° to 105° F., followed by 
a sweat between woolen blankets; internally ten grains of Dover's 
powder, or five grains of quinine with five grains of salol. Free 
catharsis should be promoted by a tablespoonful of magnesium 
sulphate. 

If these measures fail to abort the attack, then treatment with 
anodynes and anti-neuralgics should be instituted. This therapy 



Definition 



Usure des Cartilages Articulaires (Cruveillier, 1858). 

Chronic Rheumatic Arthritis (Adams, 1857). 

Rheumatisme Noueux (Trousseau, 1860). 

Arthritis deformans (Virchow, 1869). 

Rheumatoid Arthritis (Sir A. Garrod, 1876). 

Osteoarthritis (Spencer, 1888). 

Pernicious Arthritis (Brabazon, 1896). 

Rheumatisme chronique infectieux (Chauffard und Ramon, 1896) 

Rh. chr. infectieux et diathesique (Pierre Marie). 

Rhumat. chr. progressif (Charcot, Le Gendre). 

Polyarthritis villosa und Arthritis deform. (Schueller). 

Arthritis nodosa (Schuchardt). 

Osteoarthritis deformans (Schuchardt). 

Rhum. chr. deformant (Teissier und Roque). [Pribram.] 



Protection 
against cold 
and wet 



Abortion of 
the attack 



Anodynes and 
anti-neuralgics 



242 



DISEASES OE METABOLISM 



Salicylates 
Alkalies 



Acupuncture 



is based on the following principles : Patients with muscular rheu- 
matism have a tendency to voluntarily immobilize the affected 
muscles ; they do this in order to stop the pain. The arrest of the 
movement of the muscles undoubtedly retards the healing of the 
attack, for reasons that we do not understand. To discuss the 
numerous theories that have been advanced to explain this phe- 
nomenon would serve no practical purpose. So much we know that 
active movements of rheumatic muscles hasten recovery. Hence 
it is good practice to artificially stop the pain by the administra- 
tion of medicines by mouth or by local applications, for then the 
patients are enabled freely to move their muscles and in this way 
to promote restitution to normal conditions.* Internally, there- 
fore, opiates, phenacetin, acetanilid, preferably combined with 
salicylates and alkalies, should be administered either singly or in 
combination. The following prescriptions I have found very use- 
ful: 



Codeine, 


% gr. 


(0.016 gm.) 


Phenacetin, 


3 gr. 


(0.18 gm.) 


Salol, 


5 gr. 


( 0.3 gm.) 



M. S. One such capsule every three hours. 



Or 



Iv 



Extract of opium, 


% gr. (0.016 gm.) 


Acetanilid, 


3 gr. (0.18 gm.) 


Sodium salicylate, 




Sodium bicarbonate, 


aa 5 gr. (0.3 gm.) 



M. S. One such powder to be taken every four 
hours with a full glass of water. 

If these remedies do not stop the pain, then it .may become 
necessary to use morphine hypodermically, in quarter-grain doses 
repeated two or three times a day, and preferably injected into 
the sore muscles ; if the drug is administered in this way both the 
narcotic effect of the remedy and the mechanical effects of the 
puncture are utilized; for puncture alone of the affected muscles 
with a long sterile needle often acts marvelously in stopping the 
pain and, in a sense, in aborting the attack. 

In case of rheumatism of large muscles, and particularly in 
lumbago, acupuncture should be performed in the beginning of the 
attack, as a routine measure, by inserting an ordinary sterilized 



*In the case of the intercostal group of muscles, however, that 
cannot be kept quiet at the patient's will, it may become necessary, pro- 
vided these remedies do not stop the pain, to artificially immobilize the 
affected area, in order to afford temporary relief, by strapping the chest 
with broad layers of adhesive plaster. (See page — .) 



DISEASES OF METABOLISM 



243 



hat pin for four or five inches into the affected muscle and leav- 
ing it in place for from five to ten minutes. 

In addition to internal remedies heat is useful, applied by 
means of hot water bags or a thermophore, or by poultices made of 
flaxseed or bread, medicated with a few drops of the tincture of 
opium or tincture of belladonna. High degrees of heat applied by 
means of hot air and sand, as described in the next section, are ex- 
ceedingly useful, especialty in rheumatism of the muscles of the legs 
and arms. Mustard, belladonna or capsicum plasters may be used 
locally over the affected area. Iodine may be painted over the sore 
muscles. Such measures as cupping, blistering or cauterization of 
the skin over the rheumatic area are rarely necessary. Liniments, 
as chloroform liniment, or the following application, are also some- 
times effective in relieving the pain : 

Tincture of aconite^ 

Tincture of opium, of each, 2 drachms ( 4) 
Soap liniment, 3 ounces (96) 

M. S. Apply locally as directed. 

I have never been convinced that particular dietetic regulations 
or restrictions exercise any determinable effect upon the course of 
muscular rheumatism, nor that the abundant drinking of plain 
water, or of any of the numerous medicated mineral waters, in any 
way shortens the attack or prevents the recurrence of muscular 
rheumatism. However important, therefore, the regulation of 
food and drink may be in gouty forms of musculo-articular af- 
fections, in simple so called muscular rheumatism the patient need 
not be unnecessarily burdened with dietetic restrictions. 

The constant galvanic current, by causing contractions of 
the affected muscles, and massage by mechanically moving the 
muscles about, are useful adjuvants to the treatment. 



Local appli- 
cations 



Diet 



Electricity 
Massage 



CHRONIC RHEUMATISM AND RHEUMATOID 
ARTHRITIS.* 



In this disorder prophylactic treatment is occasionally effec- Prophylaxis 
tive in preventing the development of irremedial disorders about 
the joints. It seems well established that most of the cases develop 
in individuals whose vitality is low, consequently it is of paramount 
importance to counteract all extraneous influences that can reduce 
their vital powers. If an individual therefore, who comes from a 
rheumatic family, begins to complain of fleeting pains in muscles, 



*Definition see a preceding page. 



244 



DISEASES OF METABOLISM 



Dwelling and 

general 

hygiene 



Clothing 



Diet 



Water drink- 
ing 



Treatment of 
catarrhal con- 
ditions about 
the orifices of 
the body 



tendons and joints, and transitory stiffness of the fingers or the 
knees, his mode of life should be carefully regulated. 

Among the most important elements to be considered are the 
dwelling, the clothing and a variety of psychic factors. The pa- 
tient should be instructed to seek a domicile that is dry, well- 
ventilated and lights for moisture and lack of sunlight undoubt- 
edly predispose to the development of the disease under discussion. 
Living in a gloomy dwelling, moreover, exercises a depressing 
psychic influence and this, as well as any other emotional strain or 
worry, should be most carefully avoided. The patients should, 
above all, be protected against exposure to wet weather or sudden 
temperature changes; consequently, it is often important to induce 
individuals whose occupation forces them to undergo such ex- 
posures to change their mode of livelihood. 

The clothing is, of course, of great importance. Many of 
these people are anemic and react badly to temperature changes. 
Linen or cotton should never be worn close to the body ; for these 
textures favor rapid radiation of heat, become wet and cling to the 
body when the patient perspires and hence obliterate the layer of 
immovable air that should intervene between the skin and the first 
garment. Wool or flannel, or silk, are best of all for reasons that 
have been fully set forth under the head of Anemia. If the indi- 
vidual is strong enough it is always well to attempt to harden 
him (see Rhinitis), i. e., to render him less susceptible to tem- 
perature changes. 

The diet should be especially nourishing without overloading 
the stomach. The error is frequently committed of feeding these 
individuals according to the principles that are outlined under the 
Uric Acid Diathesis. This is always dangerous; for underfeeding, 
with its inevitable result malnutrition, is very apt to follow from 
this practice. It is useful, therefore, to appreciate that the uric 
acid diathesis, so-called, has nothing whatsoever to do with chronic 
rheumatism. 

The patient should be instructed to drink plenty of water, 
preferably some alkaline mineral water that possesses slightly lax- 
ative properties. This plan is always indicated, for, in many of 
the cases the alkalinity of the blood is slightly reduced. 

The infectious character of some varieties of chronic rheuma- 
tism cannot be denied, consequently great care should be exercised 
in removing catarrhal conditions about the orifices of the body, for 
.they undoubtedly constitute an open port of entry for any micro- 
organisms that might be incriminated with producing the disorder. 
Inasmuch as women seem to be particularly liable to chronic rheu- 
matism, special care should be bestowed upon diseased conditions 
in the female sexual apparatus. 



DISEASES OF METABOLISM 245 

The disease occasionally starts in with more or less acute arth- Treatment of 
ritic manifestations, or acute manifestations appear as exacerba- bations 
tions during the chronic course of the disease. Whenever the joints 
are acutely affected the patients should be put to bed on a restricted 
diet consisting largely of milk, alkaline waters and some fresh 
fruits or vegetables, and the joints should be immobilized. Great 
care, however, should be exercised not to immobilize the joints too Immobiliza- 
completely or for too long a time; for otherwise, irremediable ad- joints 
hesions and ankylosis may form. The chief object of the tem- 
porary immobilization is to reduce the pain by preventing contact 
and friction between the inflamed, opposing structures within the 
joints. Permanent extension has also been recommended. It acts 
beneficially by causing relaxation of the muscles and tendons, thus Extension 
separating the condyles and again preventing friction and pres- 
sure upon the joint cartilages. 

In order to reduce the swelling and stop the pain linen band- Moist dressing 
ages dipped in salt water may be applied. The bandages need not 
be changed every day but may remain in place for three or four 
days in succession, provided they are kept moist during all this 
time. The application of bandages moistened with 2 per cent, car- 
bolic acid was formerly very popular, but a number of cases of gan- 
grene from this source have been reported, so that this practice 
must be considered dangerous. A 20 per cent, alcoholic solution of 
salicylic acid with a few drops of chloroform occasionally aids 
greatly in relieving the pain. Very good formulae for local appli- 'Local appli- 
cations of this kind are the following : 

Salicylic acid, 10 gm. 

Alcohol, 50 cc. 

Castor oil, 100 cc. 
M. S. Apply locally. 

A teaspoonful of this mixture is rubbed into the joint and the 
member then covered with silk or rubber and wrapped in cotton or 
flannel. 

Or an ointment may be applied, consisting of : 

Salicylic acid, 10 gm. 

Oil of terebinth, 10 cc. 

Lanolin, 30 gm. 

Paraffin, 50 gm. 
M. S. Apply locally. 



246 



DISEASES OF METABOLISM 



Guaiacol 



Injections into 
the joint 



Ointments 



Internal medi- 
cation 



Guaiacol 

Beta-naphthol 
Thiocol 



Salicylates 



Or a medicated collodion may be painted upon the joint, pre- 
pared as follows: 



» 



Methyl salicylate, 
Spirits of menthol, 
Elastic collodion, 
M. S. Apply locally. 



10 cc. 

5 cc. 
5 cc. 



One of the most popular preparations, finally, is guaiacol 
mixed with equal parts of glycerin, or with the tincture of iodine, 
in the proportion of one part of guaiacol to six parts of the tincture 
of iodine. 

Injections into the joint of iodoform emulsions of guaiacol 
have also been used ; the formula recommended being : 



R 



Iodoform powder, 

Glycerin, 

Guaiacol, 

M. Sig. For injection. 



5 gm. 
60 cc. 
20 drops 



In case the pain about the joints is very violent, then opium 
or belladonna ointments or chloroform liniments must be applied, 
or hypodermics of morphine must even be administered. Counter- 
irritation with iodine frequently relieves. If there is very much 
swelling, then paracentesis of the joint, followed by the injection 
of the above iodoform-guaiacol preparations may be practised. 

For internal use innumerable remedies have been recom- 
mended, but none of them has fully vindicated the claims to real 
efficacy in this disease. Guaiacol preparations should always be 
tried. The carbonate of guaiacol is better than pure guaiacol as it 
is less irritating to the stomach and kidneys. The carbonate should 
be given in doses of five to fifteen grains (0.3 to 1 gm.) three or 
four times a day. Next in popularity to guaiacol carbonate is beta- 
naphthol. 

In many chronic articular disorders of unknown etiology a 
careful trial with thiocol is indicated. It apparently exercises an 
antiseptic action locally, in case the joint affection is due to bac- 
terial influences. The drug can be taken for weeks and months 
in daily doses of from 2 to 4 grams without any untoward symp- 
toms; in fact, a mildly stimulating effect upon the appetite and 
upon the general condition of the patient is generally observed. 

Salicylic acid preparations are of subordinate value in the 
treatment of chronic rheumatism. In view of the difficulty^ how- 
ever, of distinguishing clinically between the various forms of sub- 
acute rheumatism, it is often worth while to give salicylate prep- 



DISEASES OF METABOLISM 



247 



arations, either in the form of salol five to ten grains (0.03 to 0.65 
gm.) three or four times a day, or as aspirin in the same doses. 
The so-called alkaline-quinine treatment, that is, the combination 
of quinine two to five grains (0.1 to 0.3 gm.) and sodium carbon- 
ate five to ten grains (0.3 to 0.6 gm.) may also be employed, if all 
other measures fail, for occasionally good results are seen from this 
medication. 

Fibrolysin is worthy of trial, although there seems to be no 
definite consensus of opinion in regard to its efficacy. I am under 
the impression that in some cases of arthritis deformans it pro- 
duces marked objective and subjective improvement when used in 
combination, of course, with other measures. 

Fibrolysin should be injected twice a week in the dose of 2 to 
3 cc. into the subcutaneous tissues. Following the injection a lit- 
tie pain and itching, occasionally a little redness, swelling and ir- 
ritation of the skin are noticed. I have never, however, seen any 
6erious after-effects^ the swelling usually disappearing within a 
few days. One should be very patient in expecting results from 
this medication and from 30 to 40 injections are usually required 
before any definite results are obtained. 

As soon as the acute and sub-acute stages are over, or if the 
case comes under observation for the first time with a fully devel- 
oped case of chronic rheumatism, then treatment should be di- 
rected almost exclusively towards promoting absorption of the exu- 
dates that may be present, towards preventing the formation of 
ankylosis and contractures, or toward loosening the ankylosis and 
relieving the contractures if they have already formed. 

In order to fulfill these objects dietetic and medicamentous 
measures are of very subordinate importance. What remedies are 
given should be administered as general tonics, or in order to cor- 
rect any anemia that may be present, or, symptomatically, to re- 
lieve pain or other disagreeable local symptoms; thus strychnine, 
quinine, iron, arsenic and occasionally guaiacol carbonate, salol, 
beta-naphthol, and the other remedies that have been enumerated 
above when discussing the drug treatment of the acute and sub- 
acute arthritic manifestations of chronic rheumatism, may all be 
utilized. , The chief reliance, however, should be placed upon ex- 
ternal measures. Neither diet nor drugs can accomplish much in 
this disease. Local external treatment will accomplish everything 
that one can reasonably expect to see brought about. 

Heat in various forms must be applied to the affected joints. 
Hot baths, plain or medicated, mud baths, sand baths, steam baths, 
sun baths, hot air baths, may all be used. All of these baths act 
by accelerating the circulation of lymph and blood in the diseased 



Salol 
Aspirin 

Alkaline- 
quinine treat- 
ment 

Fibrolysin 



Treatment of 
fully devel- 
oped stage 



Subordinate 
importance of 
drugs 



Value of ex- 
ternal appli- 
cations 



Heat 



248 



DISEASES OF METABOLISM 



Baths 



Resort and 

institution 

treatment 



Extravagant 
claims of pro- 
moters of re- 
sorts and 
waters 



Mud baths 



joints, and hence promoting absorption of liquid, semi-solid or 
solid exudates that may have formed. 

The temperature of the bath and the length of time during 
which the hot applications are to be made vary in each individual 
ease and no fixed rules can be formulated. One cardinal rule 
should always be observed, however, viz., that, in the beginning 
of the treatment, very high temperature should never be employed. 
If the individual is suffering from nervous disorders or from dis- 
turbances about the circulatory apparatus, then any bath treatment 
should be begun with great care and under careful supervision of 
the nervous reaction, the blood pressure and the condition of the 
heart and arteries. 

Inasmuch as the bath treatment must be carried out consistent- 
ly for long periods of time, sometimes for months, before very ap- 
preciable effects become noticeable, and as proper facilities for this 
treatment are only with difficulty procured at home, it is usually 
necessary to have such patients undergo their bath cure in certain 
watering places or institutions that are especially equipped for 
these treatments. The number of these resorts is legion and in 
selecting an institution or a watering place one should be gov- 
erned by the circumstances of the patient, the time at his disposal 
and many other extraneous factors that need not be enumerated. 
The chemical composition of the water at different resorts has 
very little to do with the good effects of these waters, nor is there 
anything to indicate that the addition of various medicinal sub- 
stances as pine needles, turpentine, carbonate of soda or potash, 
sulphid of potassium, arsenate of soda, formic acid, etc., to the 
bath water exercises any specific effect upon the disease process 
that could not be obtained by the use of plain hot water. The 
addition of salt and other slightly irritating ingredients to the wa- 
ter may enforce the action of the heat ? inasmuch as they produce 
increased hyperemia of the skin and hence more active and pro- 
longed dilatation of the superficial capillaries, with a correspond- 
ingly increased blood and lymph flow through the underlying joint 
structures. The slight advantage accruing from this effect is al- 
most negligible, however, so that the extravagant claims advanced 
by the promoters of different resorts and waters in this country 
and abroad, in regard to the wonderful efficacy of their particular 
spring in curing chronic rheumatism, may be dismissed without 
further comment. It all depends upon the regime at these different 
places, the facilities for securing proper massage and the method 
of applying the hot water, but not upon the chemistry of the wa- 
ters used. 

A very convenient method of applying high degrees of tem- 
perature to the affected joints is by the aid of mud baths, for 



DISEASES OF METABOLISM 



249 



the mud particles irritate the skin and also exercise pressure upon 
the affected joint, in both these ways enforcing the action of the 
heat and promoting more rapid absorption of the pathologic exu- 
dates. Here, again, it is the heat and the physical properties of 
the mud and not the chemical constituents it may contain that 
exercise the good effects. 

For domestic application sand baths are exceedingly useful, for 
very high temperature can be applied with the aid of sand. The 
hot sand (up to 150° F.) may be filled into little linen sacks and 
applied to the joints ; in this way the benefits of both pressure and 
heat are obtained. The length of time during which the applica- 
tion is made varies according to the sensations of the patient. If 
the finger joints alone are involved it is a very useful plan to have 
the patient put on a cotton glove and immerse his hand in the 
sand, holding it there for fifteen minutes to an hour at a time, 
several times a day. 

The most effective way of applying heat, and the one that 
permits the use of the highest temperature, is by means of hot 
air. Special apparatus of different makes are on the market which 
enable the patients to carry out this treatment at home. Tempera- 
ture as high as 300 to even 400 degrees F. can be borne without 
discomfort. Dry heat used in such an apparatus makes it possi- 
ble to treat one joint at a time while the rest of the body is pro- 
tected from the heat ; this prevents disagreeable and dangerous phe- 
nomena about the nervous and circulatory apparatus. 

Sun baths and electric light baths are also employed in certain 
institutions and occasionally fulfill a useful purpose. Here again, 
the heat is the active agent and not, as far as we know ; the chemical 
rays of the light. 

In some institutions the mechanical effect produced by a 
stream of hot water directed against the joints is utilized to ad- 
vantage to promote the circulation in the joint and to enforce the 
effect of the heat. One of the best plans is the so-called "Scotch 
douche." Here the temperature of the stream of water which is 
directed against the affected joint with considerable force is rapidly 
changed from hot to cold and back again, and a very marked effect 
is generally produced in this way. 

A method that has recently come into deserved popularity is 
the production of passive hyperemia in the affected joint. This is 
the so-called Bier method. In order to produce passive hyperemia 
a bandage is wrapped around the limb above the joint. It is ap- 
plied so tightly that the region about the joint becomes bluish- 
red in color and swollen. The application of the bandage should 
never produce pain in the affected articulations. Occasionally a 
little throbbing is complained of in the beginning, but even this 



Sand baths 



Hot air 



Sun baths 
Electric baths 



Douches 



Bier's method 
of passive 
hypermia 



250 



DISEASES OF METABOLISM 



Massage and 
movements 



Electricity 



Orthopedic and 
surgical treat- 
ment 



Reduction 
obesity 



of 



disagreeable sensation should disappear within a short time. The 
constriction should at first be continued for several hours at a time, 
later for all day ; still later the bandage is applied only during the 
night. No harm has ever been known to follow this method of 
treatment and some of the results reported are exceedingly satisfac- 
tory, so that it certainly deserves extended trial. 

The application of heat by any of the means mentioned above 
can usually be supplemented to advantage by proper massage and 
by active and passive movements of the affected joints. Here, too, 
the improvement of the circulation that follows the massage aids in 
the absorption of the pathologic exudates. Inasmuch as this treat- 
ment should be performed by a skilled operator it is needless to 
discuss the technique of massage. 

Electricity has been used in many cases of chronic rheumatism 
with good results, either alone or combined with heat and me- 
chanical treatment. The electric current undoubtedly exercises a 
distinct effect upon the circulation in the skin and the underlying 
parts, and may, in this way, aid in promoting a more rapid flow of 
lymph and blood through the affected area. This method of treat- 
ment, too, should be carried out by an expert, otherwise it is usual- 
ly futile. The faradic brush and the solenoid current are particu- 
larly recommended. Eecently good results have also been reported 
from high frequency currents, but this question is still in abey- 
ance. 

In the later stages of the disease when ankylosis and deformi- 
ties have occurred, orthopedic and surgical treatment often becomes 
necessary. In this connection the importance of reducing obesity 
in sufferers from chronic rheumatism of the joints may again be 
referred to, for the reduction of the weight of the person of neces- 
sity relieves the joints of much pressure and saves them the labor 
of supporting a huge bulk ; hence a reduction cure acts in the same 
sense as the mechanical supports that are given these patients by 
orthopedic surgeons. The various surgical procedures that have to 
be instituted in deformed cases cannot be discussed within the com- 
pass of this book. 



Introductory — 
The principles 
underlying the 
treatment of 
the uric acid 
diathesis 
The neurosal 
element 



GOUT AND THE URIC ACID DIATHESIS.* 

Of the primary causes of the uric acid diathesis we know noth- 
ing. Theoretically, I place myself without equivocation upon the 
neuro-humoral viewpoint so ably defined by Duckworth in the fol- 
lowing words: "It is incumbent, I believe, to invoke not only a 
chemical and a physical basis for gouty disease, but to include 



♦Synonyms: Lithemia; Urichemia; Atypical, irregular, incomplete 
or abarticular Gout. 



DISEASES OF METABOLISM 251 

also in a comprehensive review the marked determining influence of 
the nervous factor in the problem." 

The neurosal element is vague and intangible, essentially hered- 
itary and probably not remedial in one generation. The perversions 
of the uric acid chemism on the other hand are more definite and 
are amenable to considerable modification and to correction by 
treatment. 

There is immense confusion in this field. This may be due to 
the fact that the course of typical gout is per se irregular and sub- 
ject to fluctuations, and that atypical gout* presents so protean a 
syndrome of functional disorders, involving almost every organ, 
that the doors are thrown wide open to subjective misinterpreta- 
tion. 

In seeking for a basis of treatment the fundamental perversions 
characteristic of the uric acid diathesis must be determined. They 
are the following: 

1. The uric acid of the blood is increased. 

2. Crystalline deposits of sodium urate are found in certain The increase 
. • i- of uric acid 

necrotic tissues. in the blood 

The former factor alone, however, by no means constitutes the 
essential element of the so-called uric acid diathesis, for in several 
diseases, notably leukemia, the circulating and excrementitious 
uric acid may be increased immensely without ever producing any 
of the symptoms or lesions of gout or goutiness. It is safe, on the 
other hand, never to include a case under the category of the uric 
acid diathesis unless the uric acid of the blood is increased. 

The increase of uric acid in the blood may be due to: (1) In- 
creased formation of uric acid; (2) Decreased destruction of uric 
acid; (3) Retention of uric acid; or to several of these factors Uric acid de- 
combined. ***» 

The analytical formation of uric acid, i. e., the genesis of uric 
acid from the disassimilation of more complex compounds, is the 
common mode of formation in man. The old view is that uric acid 
is an oxidation product of albumin and an intermediary product 
in the formation of urea; the new view is that uric acid is a spe- 
cific metabolic product of a special kind of albumin, viz., nuclein. 

ISTucleins are the chief constituents of all cell nuclei and are 
hence contained in many articles of food and also in the tissues of 
our own body ; uric acid may therefore be derived from either. As Endogenous 
a matter of fact, the administration of nuclein or nuclein-contain- JJJJ? e * c °§ en ° US 
ing foods by the mouth is followed by an increase of the uric acid 
excretion in the urine. On the other hand, a subject fed for a long 
time on a diet containing no nucleins (see below) y or a subject after 
a prolonged period of fasting, still excretes appreciable quantities 
of uric acid. In the former instance the urinary uric acid was 



252 



DISEASES OF METABOLISM 



Transforma- 
tion of uric 
acid 



Retention of 
uric acid 



The effect of 
diet on the 
uric acid ex- 
cretion 



derived from the food nucleins; in the latter the excreted uric 
acid was derived from the tissue rmcleins. 

The formation of uric acid from the food nucleins we can 
control; the formation of uric acid from our tissue nucleins we 
cannot control. Whereas the former factor is constant and inde- 
pendent of the individual, in the sense, namety, that a definite 
quantity of food nuclein invariably leads to the excretion of a 
definite and calculable quantity of uric acid, the latter factor is 
inconstant, varies in different individuals, and cannot be calcu- 
lated in advance. 

The theory has been advanced, and has been supported by 
some evidence, that in subjects suffering from the uric acid dia- 
thesis the individual catabolism of nucleins is high; the adherents 
of this view consider the diathesis a "nucleolytic auto-intoxica- 
tion" — which proposition it is difficult to prove. 

Uric acid is normally in part destroyed or transformed in the 
mammalian organism. Extracts made from liver, muscle and 
kidney in certain lower animals possess the power of converting 
uric acid into more highly oxidized and more soluble nitrogenous 
bodies. The author has shown that the same applies to human 
liver, kidney, muscle, and blood.* 

We also know that only a portion of the calculated amount of 
uric acid is excreted after feeding with nucleins or uric acid, and 
that a part of the nitrogen appears in the urine in other forms. I 
am inclined to believe that non-destruction is a more prolific cause 
of uric acid accumulation than over-production. 

Whether or not uric acid is retained in the uric acid diathesis 
cannot, I believe be definitely ascertained until we gain more com- 
prehensive data in regard to the uric acid excretion before, during, 
and after attacks of gout, and in regard to the average uric acid 
excretion in those cases that never progress to the stage of gouty 
seizures. 

We have only recently learned to understand the influence of 
diet on the uric acid excretion, and above all the influence of the 
food nucleins on this function. It is clear that uric acid deter- 
minations are of value only if the patient is kept on a diet free 
from nucleins during the time of observation, or if at least the exact 
nuclein content of the food is known; in addition, the individual 
(endogenous) uric acid excretion must be known. Failure to com- 
ply with these fundamental postulates must be made responsible 
for the colossal confusion obtaining in regard to the plus or minus 
excretion of uric acid in the disease. 

In that small minority of cases of gout in which there is dis- 
tinct granular atrophy of the kidneys some retention may occur. I 

♦Medical Record, 1903. 



DISEASES OE METABOLISM 



253 



The factors de- 
termining 
urate deposits 



am also inclined to believe that renal insufficiency obtains in a 
much larger proportion of gouty cases than is usually assumed. I 
refer to those patients in whom we find increased arterial pres- 
sure with an accentuated second aortic sound and signs of cardiac 
hypertrophy, together with certain retinal changes, nitrogen re- 
tention without increase of bodily weight, and other evidences of 
renal inadequacy; these appear to me to be cases of "latent" 
nephritis, and the absence of albumin from the urine does not 
necessarily militate against this diagnosis. 

Urate deposits are a characteristic finding in the uric acid Urate deposits 
diathesis, even though cases of gout occur in which no urate de- 
posits are found post-mortem, and though urate deposits are oc- 
casionally discovered on autopsy without a history of gouty seizures 
during life. 

It appears that urate concretions can only occur if the blood 
contains an excess of uric acid in solution; the reverse is not true, 
for in many other states (leukemia, pneumonia, lead nephritis, 
etc.) in which the blood contains abnormal quantities of uric acid 
no concretions develop. 

Definite factors must therefore be operative in the uric acid 
diathesis that not only favor the deposit of urates, but also deter- 
mine certain definite points of predilection for the precipitation of 
sodium urate crystals. These locations are the joints, the tendon 
sheaths, the muscle fasciae, the kidneys, the external ear and the 
bone-marrow. 

These factors must necessarily be local. It is very probable 
that the poor vascularization of the particular parts can largely 
be made responsible for the deposit of concretions in these special 
places. 

Much has been written in regard to the influence of reduced 
alkalinity of the blood. It does not appear, however, from exact 
determinations that the alkalinity of the blood is abnormally low 
in the uric acid diathesis. 

Changes in the relative proportion of salts (chiefly mono-and 
di-sodium phosphate) in solution in the serum are a much more 
important factor. If several salts are present in solution the more 
soluble salt will precipitate the less soluble one even if the solu- 
tion is not saturated with the latter. Given, therefore, an increase 
of urates in the blood, with local stasis of blood and lymph, then a 
slow interchange between two relatively concentrated solutions oc- 
curs, and precipitation of the least soluble salts, the urates, obtains. 

Senile cartilages are relatively rich in salts, and the circulation 
in these tissues is particularly poor ; hence possibly the tendency of 
older subjects to uratic deposits in the joints. 



Blood alka- 
linity 



Proportion of 
salts 



254 



DISEASES OF METABOLISM 



Necrosis in 
the vicinity of 
urate con- 
cretions 



General con- 
siderations rel- 
ative to 
treatment 
based on the 
above prin- 
ciples 



Chief indica- 
tions for 
treatment 



Limited use of 
uric acid-form- 
ing foods 



The destruc- 
tion of uric 
acid 



The significance of the necrosis found in the vicinity of urate 
concretions is still obscure. Either the urates produce the ne- 
crosis or the necrosis is the primary event and prepares a suitable 
nidus for the secondary deposit of urates ; the' cause of the necrosis 
in the latter event would remain unexplained; it may be tropho- 
neurotic or may be due to the action of the alloxuric bases, chem- 
ical congeners of uric acid. 

As the primary cause of the uric acid diathesis is unknown 
and as the neurosal element that enters into its pathogenesis is 
intangible, we are limited in our treatment to a correction of the 
perversions of the uric acid economy that we have outlined above. 

We find ourselves here in a similar position as in the treatment 
of diabetes and obesity, for in these diseases, too, we are limited in 
our endeavors to the removal of excessive sugar and fat and to a 
correction of the secondary disorders that follow the abnormal ac- 
cumulation of these products. Unfortunately, we have in the uric 
acid diathesis no such definite index of the progress of the disease 
and the success of our treatment, as the disappearance of sugar 
from the urine or changes in the contour of the patient. The 
two chief indications for treatment are : 

1. To prevent the increase of uric acid in the blood; this ac- 
complished, the precipitation of urates, as we have seen, is rendered 
difficult. 

2. To promote the solubility of uric acid in the blood; in 
this way its precipitation may also be prevented. 

As the accumulation of uric acid may be due to increased for- 
mation, decreased destruction, or retention^ treatment should be 
directed towards reducing the production of uric acid, increasing 
its destruction, and accelerating its elimination. 

To reduce the production of uric acid is one of the most im- 
portant, and at the same time one of the most feasible, tasks of 
dietetic treatment. We know that the uric acid is chiefly formed 
from disintegrating cell nuclei and that the restriction of articles 
of food containing many cell nuclei or nuclein or uric acid, or its 
chemical congeners, the alloxuric bases (purin bodies), must needs 
decrease the formation of uric acid. And even should it be shown 
that the accumulation of. uric acid is due to retention or non-de- 
struction, and not to over-production, the limited use of uric acid- 
forming foods must nevertheless be considered altogether rational. 

We know too little of the normal mechanism of uric acid de- 
struction to enable us satisfactorily to regulate this process. What 
means we possess to accomplish this end are not dietetic. The 
withdrawal of articles of food that are more readily oxidized in the 
body than uric acid was at one time considered to be good practice, 
for it was argued that in this way the oxidizing powers of the or- 



DISEASES OE METABOLISM 



255 



ganism would not be directed toward a destruction of these articles, 
but to the destruction of accumulating uric acid instead. Since 
it has been shown, however, that uric acid is not destroyed by a 
proper process of combustion but by a more delicate process of in- 
tracellular disassimilation (probably fermentative in character), 
this argument has been rendered altogether invalid. 

Certain dietetic regulations can finally directly and indirect- 
ly aid in the elimination of uric acid; directly, by exercising an 
effect on the circulation and the renal excretion; indirectly, by 
sparing the heart and kidneys and enabling them to perform their 
functions in a normal manner. As the latter organs are frequently 
involved in the uric acid diathesis, it is particularly important 
that the diet should contain nothing that can injure them. 

The following considerations, therefore, based on the princi- 
ples just predicated should govern the selection of the diet in the 
uric acid diathesis. 

There is much disagreement and misunderstanding in regard 
to the use of meat. One group of extremists interdicts the use of 
meats altogether ; another makes artificial distinction between dark 
and red meats; and a third insists on a diet consisting almost ex- 
clusively of red meat ("Salisbury diet"). In this country the red 
and dark meat fad is particularly rampant. I see the matter as 
follows: The use of a moderate amount of meat is not only per- 
missible but necessary. Some care must be exercised in selecting 
the kind of meat and in determining its quantity and its mode of 
preparation. 

The administration of nuclein or extractives (uric acid and the 
purin bases) should be reduced; hence all meats containing many 
cell nuclei, i. e., all internal organs (liver, kidneys, sweetbreads, 
brain, thymus) should be rigorously excluded. All meat extracts, 
broths, sauces, and gravies contain the extractives and are conse- 
quently bad. Eaw meats, smoked and cured meats, sausage, etc., 
because they still contain the extractives, should also be limited. 

To exclude the flesh of fowl because birds produce more uric 
acid than mammals is based on the erroneous conclusion that con- 
sequently their muscles are also particularly rich in uric acid. 
There is no reason to exclude poultry. 

It has also been shown by exact analyses that there is no dif- 
ference in regard to their uric acid content between the dark and 
the white meat of birds. This distinction is therefore also unnec- 
essary. 

Boiled meat is better than roast or fried meat, because the 
extractives have been removed from the former. Some writers 
maintain that the quantities of extractives introduced with meat 
are so small that they cannot possibly exercise an appreciable ef- 



Elimination 
of uric acid 



The diet 



Meat 



"Salisbury" 
diet 



Red and dark 
meats 



Nuclein con- 
taining foods 

Internal or- 
gans 

Meat extracts 
Red meats 



Fowl 



Mode of prep- 
aration 



256 DISEASES OF METABOLISM 

feet; there is, however, some evidence to show that these bodies, 
administered in small quantities for a long time, may exercise a 
cumulative effect. It is safer, therefore, to adhere to the fore- 
going rules until evidence to the contrary is forthcoming. 
Dangers of We are unable, of course, to directly control the nuclein econ- 

™ on e " omy of the organism proper by restricting the use of nuc-leins, for 
the body is capable of building up its tissue-nucleins from any 
proteid and phosphorus-containing pabulum. We know, for in- 
stance, that whole peoples live on a vegetable diet free from nu- 
cleins. (These by the way are remarkably free from gout!). 

The albumin of the meat exercises no direct effect ou the ex- 
cretion of uric acid and may therefore be considered an essentially 
indifferent constituent of flesh as far as the uric acid economy is 
concerned. The quantity of meat should, however, be limited, al- 
though not reduced too much. The organism requires a definite 
.quantity of nitrogenous material, and while it is possible to supply 
all the nitrogen required in articles of food other than meat, this 
procedure necessitates feeding the patient with large quantities of 
bulky material leaving much residue and taxing the digestive ap- 
paratus very severely. It is more natural and more rational to 
supply a portion of the nitrogen in meat, especially as the with- 
drawal of meat constitutes a great hardship to many patients and 
it would be unnecessarily cruel to stop its use. One pound of meat, 
moreover, contains as much nitrogen as several pounds of most 
other nitrogenous articles of food. 

Unless the caloric value of the diet is carefully calculated there 
is always danger of under-feeding the patients when meat is with- 
drawn. This is a dangerous possibility, for it favors the develop- 
ment of gouty cachexia, lowers the tone, and therewith reduces 
the activity of the oxygenation powers of the body. If nitrogen is 
deficient the organism, moreover, compensates for this deficiency by 
increasing catabolism of its own (nuclein-containing) tissues. 
Dangers of too On the other hand, too much meat is certainly bad, for. in the 

much meat £ rs ^ pi ace ^ m eat produces a distinct digestion — leucocytosis, fol- 

lowed by the disintegration of leucocytic nuclei; in the second 
place, meat reduces the alkalinity of the blood owing to the sul- 
phur and phosphorus it contains, for inhese elements, as we have 
seen, are oxidized to sulphuric and phosphoric acids, and as the 
bases (potassium, sodium, calcium, and magnesium) liberated 
from the meat at the same time are incapable of completely neu- 
tralizing these acids, acidulation of the bodily fluids occurs (corned 
beef is particularly bad in this respect because all the basic salts 
are leached out in its manufacture and replaced by neutral sodium 
chloride) ; in the third place, meat taxes the eliminatory powers of 



DISEASES OP METABOLISM 257 

the kidneys very much, and these organs must be spared and pro- 
tected in the uric acid diathesis. 

Eggs in moderation may be permitted. True, the yolk of egg Eggs 
contains abundant nuclein (vitellin), but this nuclein is differ- 
ent chemically from the nucleins of meat and cannot split off uric 
acid. Nevertheless, I restrict the use of yolk of egg. The white 
of the egg exercises no effect on the uric acid excretion even when 
given in large quantities ; of course, it, too, like meat albumin, can 
reduce the blood alkalinity. Where it is well borne, it is, however, 
a very convenient form in which to supply nitrogen. 

An exclusive milk diet, as advised by some, is always bad, par- Milk 
ticularly in old people; for the ingestion of large quantities of 
water incident to abundant milk drinking must needs overtax the 
heart, the arteries, and the kidneys. Milk as an addition to a 
mixed diet is good if it can be borne ; here we must individualize. 
The nucleins it contains are paranucleins and do not produce uric 
acid. Milk slightly reduces the alkalinity of the blood, owing pos- 
sibly to the generation of lactic acid and to the oxidation of its 
proteids. 

All these theoretical disadvantages are, however, over-compen- 
sated by its highly nutritious character and its powers to stimulate 
diuresis. 

In the manufacture of cheese the basic alkali salts contained Cheese 
in the milk are dissolved in the whey ; hence cheese is poor in these 
salts. The same objections can therefore be formulated against its 
use as against corned beef (see above), viz., that it acidulates the 
blood owing to the formation and incomplete neutralization of sul- 
phuric and phosphoric acids; in addition, the free fatty acids that 
cheese contains may enforce this effect. As a matter of fact the 
urinary acidity increases after a cheese diet. Empirically, cheese 
has been known to precipitate gouty attacks, and in certain regions 
of Germany where much cheese is eaten urinary calculi are said 
to be very frequent. I consequently usually exclude cheese from 
the dietary, although there is no compelling scientific reason for 
doing so. 

It has been argued that fat should be omitted from the diet in Fats 
uratic cases because it is so readily oxidized and hence prevents 
the oxidation of the nucleins. Withdrawal of fat does not, how- 
ever, exercise any effect on nuclein catabolism nor on uric acid ex- 
cretion. Excessive feeding with fat has, on the other hand, been 
known to cause an increased execretion of uric acid. 

Paradoxical as it may sound, fat is particularly indicated in 
those cases that are inclined to obesity; for if fat is added to the 
diet, the appetite is more rapidly appeased, the patients conse- 



258 



DISEASES OF METABOLISM 






Carbohydrates 



Fruits and 
''e^etables 



quently do not eat so much, and are above all not so apt to gorman- 
dize. 

As uric acid patients should be instructed to take much physical 
exercise, the addition of some fat to the diet is almost indispensa- 
ble to maintain full nutrition. 

If, therefore, certain individual idiosyncrasies, and also the 
state of the digestive apparatus, are duly considered, there is no 
valid objection to the use of fat in moderation. 

Carbohydrates exercise no appreciable effect on the uric acid 
excretion nor do they irritate the kidneys. They do, however, favor 
the development of dyspeptic disorders, because they readily un- 
dergo fermentation and because they are so bulky. 

As all carbohydrates are quite soluble and are easily absorbed 
patients living on a carbohydrate diet are very apt to ingest too 
much nutrient. Many persons, for instance, could without diffi- 
culty master 1,000 grammes of carbohydrate in the form of bread, 
cake, potato^ etc., a day whereas no one would be tempted to eat 
an equivalent quantity of fat (440 grammes) or of albuminous 
food (1,000 grammes). 

Carbohydrates, moreover, favor alimentary glycosuria and in- 
directly, the development of diabetes and obesity, both complica- 
tions that are not infrequently seen together with the uric acid 
diathesis. 

Carbohydrates should therefore be restricted. In cases com- 
plicated with diabetes or obesity they should be temporarily for- 
bidden altogether or replaced by fat. In patients suffering from 
dyspeptic complications, or in persons inclined to overeat, their 
use should also be restricted. 

Certain of the bulbous vegetables, viz., potatoes, cabbage, etc., 
contain a very large percentage of carbohydrate and very little 
proteid; as they, therefore, possess all the disadvantages of carbo- 
hydrate foods, and only very slight nutritive value in proportion 
to their bulk, they should be used sparingly in the uric acid dia- 
thesis. They are also apt to undergo fermentation and to pro- 
duce dyspeptic disorders. 

Salads and all green vegetables, on the other hand (with the 
exception of young germinating plants, such as asparagus, that 
contain much nuclein), may be given freely. They contain rela- 
tively little carbohydrate and a large proportion of salts. The 
large residue of cellulose they leave in the digestive tract stimu- 
lates peristalsis and aids in keeping the bowels open ; this is ade- 
sideratum in gouty cases. Celery and onions are to be forbidden on 
account of the irritating oils they contain. 



DISEASES OF METABOLISM 



259 



Fruit cures 



All spices and condiments should be avoided; they irritate the Spices and 
digestive tract and the kidneys and above all stimulate the appetite 
and in this way encourage over-eating. 

All fruits, either deciduous of citrous, may be permitted. The 
acid salts they contain are converted into carbonates and render 
the urine alkaline; they contain very little carbohydrate. Em- 
pirically, too, we know that they act beneficially in the uric acid 
diathesis (so-called "fruit cures"). Fruit acids exercise no dis- 
tinct effect on the excretion of uric acid, with the exception of 
tannic acid which seems to decrease it. 

Water should be the chief beverage. Forced water-drinking, Water 
however, is unnecessary, even harmful, although it is advised by 
some authors. Excessive water-drinking does not increase the ex- 
cretion of uric acid ; nor does increased diuresis by any means sig- 
nify increased excretion of urinary solids. Water in a sense is a 
distinct irritant of the renal epithelium ; in gouty nephritis, there- 
fore, and in cases of beginning renal insufficiency water in excess 
may do harm. Where there is much arterio-sclerosis, with a weak 
heart muscle, the flooding of the circulation with water can only be 
detrimental. 

On the other hand, the amount of water should not be reduced 
too much, for we know from clinical experience that this practice 
favors the formation of urinary calculi. A uric acid patient 
should therefore drink from one to one and one-half litres of water 
a day, not much more nor less. 

It is better to order the frequent drinking of small quantities 
than the drinking of large quantities at long intervals. It is a 
good plan to have the patient drink one-fourth of a litre of warm 
water immediately before going to bed; this practice occasionally, 
I believe, prevents the occurrence of nocturnal attacks of gout. 
In fact, owing to the frequency with which gouty seizures a/ppear in 
the night, it is advisable that patients as a routine measure should 
eat a frugal evening meal and should drink warm water before go- 
ing to bed. 

The favorable effects that are said to be derived from the use of Mineral waters 
numerous well advertised mineral waters are probably due to the 
water, and not to the salt in solution; the so-called uric-acid-sol- 
vent virtues of many of these salts seem highly problematical to me 
(see below). 

Tea, coffee, cocoa are usually considered bad. I think their 
use should be greatly restricted in uric acid cases. They contain 
certain members of the group of alloxuric bases (caffeine, theine, 
theobromine, adenine, etc.), and as these bodies are direct pre- 
cursors of uric acid some of them are presumably in part converted 
into uric acid in the organism ; at all events the excretion of uric 



Tea, coffee, 
cocoa 



260 



DISEASES OF METABOLISM 



Alcohol 



Exercise 



acid is increased after some of these substances are given by the 
mouth. There is, moreover, some evidence to show that these 
compounds may directly irritate the kidneys and the circulatory ap- 
paratus, also the digestive tract. 

While excessive tea or coffee drinking is, therefore, to be ab- 
solutely condemned, the moderate use of thin tea or coffee is, I 
think, permissible, particularly in persons who crave these bever- 
ages. Tea is by all means preferable to coffee ? for it stimulates 
diuresis and is not indigestible. In patients accustomed to alco- 
hol it is also much easier to limit or stop the use of the latter if a 
little tea or coffee is allowed. 

Alcohol-drinking has always been considered one of the chief 
causes of gout. In view of the almost universal prevalence of the 
alcohol habit, however, this proposition is difficult to prove. There 
can be no doubt that an alcoholic debauch may occasionally pre- 
cipitate a gouty attack in a predisposed subject, and that sufferers 
from gout as a rule feel better if they abstain from alcohol. Alco- 
hol is a direct irritant of the digestive tract, of the circulatory 
apparatus, and of the kidneys. No distinct and uniform effect of 
alcohol on the excretion of uric acid has so far been determined, 
notwithstanding the fact that a veritable flood of investigation has 
been published on this question. The food value of alcohol is of 
subordinate importance in goutiness, for here there is no loss of 
valuable pabulum in the urine as in diabetes. 

Alcohol, chiefly on empirical grounds, is, therefore, as a rule, 
to be forbidden. At the same time we occasionally encounter a 
patient who does better if a small quantity of some alcoholic bev- 
erage is permitted. Champagne, sweet wines, cider, liqueurs, and 
malted liquors are to be absolutely avoided ; dilute Rhine or Moselle 
wine or claret or whisky with water, all in very small doses, may at 
times be allowed. 

As in all the other dietary regulations that I have outlined, the 
previous habits of the patient, his temperament and character, must 
be carefully considered. 

It is frequently easier to enforce rigid rules in one direction if 
a little latitude is allowed in another, and if certain cravings and 
tastes — call them abnormal — are satisfied. "By association with 
rules that cannot be obeyed, rules that can be obeyed lose their 
authority." 

One of the most important elements to be considered in the 
treatment of the uric acid diathesis is the regulation of physical 
exercise. Broadly speaking, every sufferer from manifestations of 
the uric acid diathesis, especially when afflicted with "rheumatic" 
and neuralgic symptoms, should indulge in abundant but light 
physical exercise, carried out as much as possible in the fresh air. 



DISEASES OF METABOLISM 



261 



Massage 



Baths 



Resort treat- 
ment 



In view of the fact that many of these cases are of a melancholy or 
irascible temperament, and usually suffer from hypochondriasis, 
the exercises should partake of the character of sports, i. e., they 
should not be monotonous but should amuse and stimulate the 
patient. Moderate horse-back riding, golf, swimming, fencing, 
tennis, bicycling, rowing are all useful, and during the cold 
months, bowling, billiards and similar games. In view of the 
tendency to uratic nephritis and uratic myocarditis, that is always 
to be considered in these cases, no violent exercise should be in- 
dulged in, nor should exertion ever be carried to the point of 
fatigue. If there are nephritic or cardio-vascular changes, then 
passive and resisting exercises and massage become exceedingly use- 
ful. 

Baths also occupy an important place in the treatment of the 
uric acid diathesis. If it is possible the patient should be advised, 
for a month or so of each year, to undergo a course of treatment 
in some watering place where he can have the benefit of hot baths 
combined with massage and exercises such as those specified above. 
The careful regulation of the regime, as it is generally carried out 
in resorts, combined with rest and respite from daily work and 
worries, usually exercises a most beneficial effect upon these cases. 
The choice of the bath is difficult and I am inclined to believe that 
the temperature of the waters and the mode of administering these 
baths are more important than the chemical ingredients the waters 
may contain; it is in most cases of small importance whether the 
water contains salt or carbonic acid or sulphids, or whether a mud 
or a fango bath is given. At home warm bathing should also be Hot bathing 
encouraged and the patient should, at least two or three times a 
week, take a hot bath, a few degrees above the body temperature, 
preferably lying still in the tub for ten minutes at a time. After 
the bath a vigorous rub with a rough towel, followed by a general 
massage with cocoa butter or olive oil, is often of great value. Hot 
bathing of this kind, however, is distinctly contra-indicated in 
cases suffering from cardio-vascular or nephritic manifestations of 
the uric acid diathesis, and immeasurable harm is undoubtedly 
done in many of these cases by a routine treatment which ignores 
these elements. All hydro-therapeutic procedures, Turkish or 
Eoman baths are, as a rule, too severe for these patients, particu- 
larly in view of the neurotic complications and also the changes 
about the heart and arteries that are present in the great majority 
of them. 

The medicinal treatment of the uric acid diathesis will be dis- Medicaments 
cussed in full in the Section on Nephrolithiasis Urica, and I refer 
to those paragraphs for the use and abuse, the fallacies and incon- 



Contra-indi- 
cations 



Hydrotherapy 
in general 



262 



DISEASES OF METABOLISM 



Complications 
and sequelae 



Hepatic insuf- 
ficiency 

Dyspepsia 



Constipation 



Catarrhal con- 
ditions 



Anemia 

Diabetes 

Obesity 



Tophi 



Skin lesions 



Retrocedent 
gout 



sisteneies of most so-called uric acid remedies, particularly the 
uric acid "solvents." 

Certain complications and sequelae of the uric acid diathesis 
require special treatment. Many of these signs disappear prompt- 
ly upon the onset of a regular gouty attack and most of them are 
best treated, like the complications of diabetes and obesity, by 
correcting the underlying metabolic perversion. In view of the 
important part that the state of the digestive apparatus plays in 
the production of lithemic manifestations, particular attention 
should be bestowed upon the gastro-intestinal tract and the liver. 
Here the syndrome of functional hepatic insufficiency must always 
be considered and treated, as described in the Chapter on Diseases 
of the Liver. If the diet is arranged as outlined above gastro- 
enteric symptoms are not very liable to supervene; if they should 
appear, their symptomatic treatment differs in no way from that 
of other forms of gastric or intestinal dyspepsia, as elsewhere de- 
scribed. Constipation is very common and should be energetically 
combated. Intestinal putrefaction should never be permitted to go 
on unchecked. For this reason free evacuation of the bowel con- 
tents, either by the use of vegetable cathartics or preferably of 
salines, should be promoted, and, in addition, such remedies admin- 
istered that we know can hold intestinal putrefaction in check. 
The latter have been discussed in full under the heading of Intes- 
tinal Antisepsis (see index). The chronic catarrhal conditions 
about the throat and respiratory apparatus ; the skin affections ; the 
"rheumatic" pains in the muscles; the anemia and cachexia; the 
nephritic manifestations ; complicating diabetes and obesity, should 
all be attacked by trying to correct the perversion of the patient's 
metabolism chiefly by diet, exercise and hydrotherapy, and, in ad- 
dition, symptomatically as described under these different diseases. 

The tophi rarely call for special treatment. Particular care 
should be taken not to remove them surgically nor to allow patients 
to try to squeeze or scratch the concretions out; for in the uric 
acid diathesis there is an increased vulnerability of the skin and 
subcutaneous tissues,, so that even mild surgical procedures or sur- 
face injuries frequently induce erysipelas, cellulitis with ulcers 
and obstinate fistula? or even gangrene of the parts. 

Before discussing the treatment of the acute attack of gout, 
the general principles that should govern the treatment of so- 
called retrocedent or metastatic gout may be briefly considered. 
RETROCEDENT GOUT. 

It is well known that occasionally the joint manifestations of 
gout will rapidly disappear and in their place a variety of dis- 
tressing and dangerous cerebral symptoms develop. The latter 
manifest themselves as cerebral gout by headache, vertigo and even 



DISEASES OE METABOLISM 



263 



Induction of 
regular artic- 
ular paroxysm 



apoplectic seizures (gouty encephalopathy) ; as cardiac gout by 
severe cardiac pain, syncope or collapse; as g astro-intestinal, vesi- 
cal or cutaneous gout with corresponding manifestations. 

The sovereign therapeutic indication in all of these cases is 
to reinduce a regular articular paroxysm. This can best be done 
either by placing the feet into hot mustard water or by rubbing the 
dorsum of the foot, and particularly the large toe, with an alco- 
holic solution of turpentine followed by the application of heat, 
and wrapping the parts in cotton. The cerebral symptoms, pro- 
vided they do not promptly disappear when the articular paroxysm 
is produced, should be treated by the application of cold to the head 
and by venesection. If the stomach symptoms predominate, then 
vomiting should be produced by the use of emetics and counter- 
irritation over the epigastrium, preferably cold. The heart col- 
lapse calls for the use of analeptics^ scil. camphor, ether and the 
application of cold over the precordial region. 

THE ACUTE ATTACK OF GOUT.* 

Any attempt to abort the acute paroxysm of gout is to be con- Danger of 
demned; for by suppressing local symptoms much danger can ^ a °^xvfms Ute 
arise to the organism at large. The local treatment consists in the 
immobilization of the affected joint, the patient remaining in a re- 
cumbent position, at least in the beginning, with the diseased limb 
elevated and covered with cotton or flannel. No pressure should 
be exercised upon the affected joint. Cold should never be applied, 
because it retards the circulation and aggravates the local condi- 
tion, and may even lead to the development of necrosis and to the 
permanent deposit of urates. 

A variety of lotions have been recommended for local use. Lotions 
Whisky and water applied on lint is very grateful, or a drachm of 
sulphuric ether in six ounces of water may be used. Laudanum 
and water and belladonna liniment with morphia are recommended 
by Garrod. 

The following liniment is advised by Duckworth : 

Atropin ? 3 grains 

Morphine hydrochlorate, 15 grains 

Oleic acid, 1 ounce 

M. 

S. To be painted over the painful joint with a 

large camel's hair brush and carded cotton to 

be superimposed. 



paroxysms 

Local treat- 
ment 

Immobilization 



♦Acute paroxysms of gout are rarely seen in this country. Inas- 
much, therefore, as my personal experience with this manifestation of 
the uric acid diathesis is relatively limited, I submit in broad outline 
the combined authoritative statements of Duckworth, Garrod, Roberts 
and Latham on the treatment of this disease. 



264 



DISEASES OF METABOLISM 



Anodyne ap- 
plications 



Blisters and 
leeches 



Heat 
Massage 



Internal treat- 
ment 



Purging 
Colchicum 



Preparations 
of colchicum 



Camphor-menthol, made by rubbing up together three parts 
of menthol with two of camphor, forms a useful anodyne applica- 
tion; or half an ounce of menthol may be dissolved in six 
ounces of spirits of camphor for a lotion. Any application that 
occludes the sweat ducts, like collodion or medicated powders, 
should be eschewed. Blisters and leeches should never be applied, 
as the skin over the affected joints is usually very vulnerable and 
there is always danger of producing obstinate eczema, furunculosis 
or even gangrene. Heat is always grateful, preferably applied in 
the form of hot fomentations or poultices. Massage of the affected 
joint should be reserved until the third or fourth day of the par- 
oxysm, but had better not be administered in the beginning of the 
attack. Usually the pain produced by the massage, or by any 
movement of the joint, of itself forbids this measure. 

The internal treatment of the acute gouty attack consists in the 
administration at once of a purge. One or two grains of calomel 
with two to six grains of the compound pill of colocynth and ex- 
tract of hyoscyamus (Pil. colocynth et hyoscyami, B. P.) should 
be given at night, followed in the morning by a Seidlitz powder 
or some other saline aperient. 

As soon as the attack is fully developed colchicum becomes 
the sovereign remedy. This drug may be considered almost a 
specific, at least for relieving the pain in a gouty paroxysm. In 
order to continue the laxative effect inaugurated by the calomel, 
colocynth and hyoscine, twenty grains of carbonate of magnesium 
may be added to each dose of colchicum. The favorite prescrip- 
tion employed in St. Batholomew's hospital is the so-called Haustus 
Colchici, containing: 

Magnesium carbonate, 10 grains 

Tincture of colchicum seed, 20 minims 

Peppermint water^ 1 ounce 

A full dose to be given every night ; half the dose in the morn- 
ing. 

The treatment is continued for three or four days and then two 
or three grains each of the extract of colchicum, combined with a 
compound colocynth pill (see above), are given every night. 

The most satisfactory preparation of colchicum is the wine; 
for it does not possess such violent purgative properties as the 
preparations of the seed. The use of colchicine either by mouth 
or hypodermically is condemned as useless and not without dan- 
ger by leading authorities. The symptoms of colchicine intoxica- 
tion consist in depression, nausea and purging, and sweating, the 



*See also Chapter on "Intoxication." 



DISEASES OF METABOLISM 



265 



stools assuming a characteristic green color. It is rarely neces- 
sary to give the drug in such large doses that purging is produced. 
The appearance of severe depression and violent purging, and a 
great fall in the arterial pressure with profuse sweating, call for 
a reduction of the dose or temporary discontinuation of the remedy. 

Sodium salicylate also enjoys great popularity. In order to 
do any good it should be given in large quantities of from one 
to two drachms (4 to 8 gm.) a day, in doses of fifteen grains (1 
gm.), repeated four or eight times during the twenty-four hours. 
Very frequently the good effects of salicylates persist only for two 
or three days, then the common anti-neuralgics, phenacetin, anti- 
pyrin, aspirin, etc. (see index), may be given. Urocine and sidonal, 
the former the lithium salt, the latter the piperazin salt of quinic 
acid, are also recommended, but they are by no means so effective 
nor so reliable as colchicum or the salicylates. Most clinicians 
speak very highly of the use of the alkalies, viz.^ sodium, potassium 
and lithium carbonate or citrate, in acute gout. 

The diet during the acute paroxysm should consist largely of 
milk, bread, toast, crackers and cereals, and broths. Fresh fruits 
and vegetable acid foods should be omitted from the dietary. The 
patient should drink large quantities of water, preferably some al- 
kaline mineral water. Alcohol should be absolutely forbidden. 

In order to prevent the recurrence of acute attacks of gout 
during the stage of convalescence, the wine of colchicum, given 
in small doses, is the best remedy. Duckworth recommends five 
or six drops of the wine or tincture twice a day, or a grain of 
the extract in pill at night, to be continued for a long time after 
the subsidence of the acute attack. 

Occasionally the pain in the joint persists for a long time after 
the acute paroxysm is over ; here the iodide of potassium or of am- 
monium, in doses of five grains (0.3 gm.) three times a day, pre- 
ferably combined with five to ten drops of the wine of colchicum, 
is the best remedy. 



Sodium sali- 
cylate 



Anti-neuralgic ! 
Quinic acid 

Alkalies 
Diet 



Water 

Alcohol 

To prevent re- 
currences 



Iodides 



RACHITIS. 

This disease, as the names rachitis and rickets indicate, is Definition 
commonly interpreted to be a disease of the bony structures of the 
body. While the bony deformities are a prominent symptom they 
are by no means the determining manifestation of the disease. 
Eachitis must be regarded as a general nutritional, i. e v a meta- 
bolic disorder. The diagnosis, it is true, is, as a rule ? made from 
the bony changes, namely, the square head, the open fontanelles, 
the beaded ribs, the enlarged bone ends, the curved arms and legs, 
the pigeon breast, the contracted pelvis, the deformed spine, and 



266 



DISEASES OF METABOLISM 



Prophylaxis 



Hereditary 
element 



Syphilis and 
rickets 



General 
hygiene 



backwardness in teething. As important as the osseous deformi- 
ties, however, are the involvement of the lymph glands and the en- 
largement of the liver and spleen, the general muscular flabbi- 
ness, the anemia, the catarrhal condition of all the mucous mem- 
branes and the instability of the motor system with the well-known 
tendency to convulsions, tetany, laryngismus stridulus, glottis 
spasm, and tonic contractions about the hands and feet. 

Intelligent prophylaxis can often prevent the onset of the dis- 
order. That we may institute the necessary preventative measures 
and properly treat the disease after it is fully developed, it is 
necessary to analyze the underlying etiological elements that pro- 
duce rachitis. A great number of factors have been accused of 
causing rickets. An inherited tendency has been incriminated, as 
well as congenital syphilis, poor general hygiene, lack of light and 
air, and, above all, a variety of food factors. A careful analysis of 
all these causes shows that the most important element of all is the 
food factor. 

As far as the hereditary element is concerned there is no definite 
evidence to show that rachitic parents are more apt to have rickety 
children than healthy parents. This is readily understood when 
one considers that rickets is a disease of childhood and never per- 
sists into adult age so that the existence of rickets in the parent at 
one time may not be easy to determine. As a matter of fact, 
rickety children, as a rule, are the off-spring of healthy parents 
who never showed rickety tendencies during their childhood. Fetal 
rickets, so-called, is probably not rickets at all, but a form of cretin- 
ism. Congenital rickets undoubtedly occurs, but only if the health 
of the mother is poor ; here a nutritional and not an hereditary ele- 
ment is at play. 

Congenital syphilis, according to the best authorities, does not 
produce rickets. In most cases of rickets the typical syphilitic 
phenomena are absent and, on the other hand ? most cases of con- 
genital syphilis do not show rickety signs. The combination of the 
two undoubtedly can, and frequently does, occur, and in this way a 
peculiar disease picture is created in which it is often difficult to 
distinguish the syphilitic from the rachitic elements. 

That lack of light and air, and life in damp, dark dwellings 
alone cannot produce rickets is made manifest by the frequent ap- 
pearance of rickets in children of the well-to-do classes who live 
under ideal hygienic conditions. That malhygiene by favoring 
malnutrition and lowering the tone of the infantile organism can 
favor the development of rickets, provided food errors are at the 
same time committed is, of course, self-evident, A child, however, 
may live in the most unhealthy surroundings without developing 
rickets, provided it is fed according to correct principles. 



DISEASES OF METABOLISM 



267 



That the quantity of food, finally, does not produce rickets 
is made clear by the appearance of the disease in fat children, 
while, on the contrary, children in advanced stages of atrophy may 
not develop, in fact, rarely do develop, rickets. Broadly speaking 
the statement can be made that qualitative, and not quantitative, 
errors of feeding produce most cases of rickets. It is also impor- 
tant to note in passing that breast-fed children, provided the moth- 
er is healthy, hardly ever develop rickets, whereas, children who are 
fed on artificial foods, particularly of the farinaceous variety, are 
very apt to develop the disease, unless a sufficient quantity of ani- 
mal albumen and fat, as will be presently shown,, is added to the 
diet. 

The question arises what elements are deficient in the food of 
children who develop rickets ; and what elements must therefore be 
supplied in order to prevent the development of the disease. 

As the percentage of lime salts in rachitic bones is below nor- 
mal, the theory has been advanced that the disease is due to de- 
ficient mineral matter, especially lime salts, in the food. This 
postulate is refuted by the observation that children living on far- 
inaceous foods which contain an abundance of lime salts are par- 
ticularly liable to develop the disease, and by the further observa- 
tion that the addition of lime water to artificial foods is in no 
way capable of preventing rickets. 

Some clinicians believe that the lactic acid produced by the 
fermentation of imperfectly digested starchy foods in the stomach, 
can be made responsible for the development of rickets; they as- 
sume that lactic acid entering the circulation dissolves the lime out 
of the bones. This theory is opposed by the observations that rick- 
ets develops in individuals who are not suffering from fermentative 
dyspepsia and who readily assimilate all the starchy food that is 
given them; besides, rickety children improve rapidly if the farin- 
aceous diet is continued and if only sufficient proteid and fat is 
added to the diet. Finally, free lactic acid could never circulate 
in the blood, for it would at once combine with alkalies and cir- 
culate as lactate, that is, in a form that could not dissolve the lime 
salts of bones. 

The preponderance of all positive evidence submitted indicates 
clearly that in all cases of rickets three elements chiefly are lacking 
from the food; namely, a sufficient quantity of animal fat, of 
animal proteid and of earthy phosphates. 

Cheadle expresses himself as follows in regard to the deficit 
of fat, proteid and lime phosphate in rickets : "The dependence of 
rickets on the deficiency of these three elements of food would ex- 
plain something more than the mere bone changes ; it would clear- 
ly explain the imperfect nutrition of brain, muscle and nerve 



Quantity of 
the food 



What elements 
are deficient? 



Lime salts 



Lactic acid 



Three elements 
lacking, viz., 
fat, proteid, 
and earthy 
phosphates 



268 



DISEASES OF METABOLISM 



Gastro-intes- 
tinal disorders 



Prophylaxis 



Raw meat 
juice 



structure, which mere excess of lactic acid or absence of lime salts 
would not account for. It explains, moreover, why rickets is so 
prevalent in large towns and dense populations, where milk is so 
scarce and dear, deprived of cream and watered, and the poor 
driven to feeding their children on the cheaper farinaceous foods." 

One other etiologic factor must be mentioned, viz., chronic gas- 
trointestinal disorders, especially if they produce vomiting and 
diarrhea. Whenever such disorders are present the child prac- 
tically becomes starved despite the administration of plenty of 
food; the proteids and fats chiefly are wasted under these circum- 
stances because they must undergo certain preliminary changes, 
which require time, before they can be assimilated, whereas, the 
carbohydrates, being ingested largely in the form of sugar of milk, 
are promptly absorbed. This explains why cases of rickets oc- 
casionally develop in dyspeptic children who are fed on good cows' 
milk diluted in the proper proportion and containing all the ele- 
ments that make up the correct diet for the child. 

From all that has been said the prevention and cure of rickets 
is a comparatively simple problem, and in few diseases are so grati- 
fying results obtained from proper feeding. In rickets, above all 
things, the gastro-intestinal tract, for reasons mentioned in the pre- 
ceding paragraph, should be treated in such a way that catarrhal 
conditions are corrected. The food, moreover, should contain an 
abundance of animal proteid, of animal fat and of phosphate of 
lime. 

In view of the fact that many children cannot digest large 

quantities of milk casein, which would be the ideal proteid, the 

deficiency of animal albumen must often be supplied by raw meat 

juice. This is prepared as follows : Steak is finely chopped up and 

stirred with cold water in the proportion of one part of water to 

four parts of meat; this mixture is allowed to stand for half an 

hour in the cold and the juice is then expressed through a cloth 

or through a meat press. The meat juice obtained in this way is 

very rich in albumen and extractives and constitutes an ideal means 

of supplying nitrogen. The meat juice can be mixed with milk 

without coagulating it and without perceptibly flavoring it. It 

also renders the milk coagulates fine and flocculent. The quantity 

of this raw meat juice that may be given in the place of casein is 

from one and one-half to three ounces in the twenty-four hours. 

In preparing an artificial mixture with meat juice the amount of 

casein, therefore, that is withheld should be calculated and an 

equivalent amount of meat juice added.* 

♦The rules governing the exact proportions of proteids, fats, carbo- 
hydrates and mineral salts that should be contained in the different 
artificially prepared infant foods for different ages cannot be discussed 
within the narrow frame of this book. I must refer for information on 
this subject to text-books on Pediatrics. 



DISEASES OF METABOLISM 



269 



That the meat juice should be prepared fresh every day and 
kept in a cool place need hardly be emphasized, for, otherwise, de- 
composition, with the formation of highly irritating poisonous 
products, may occur. The deficit of fat should be made up by the 
addition of a sufficient quantity of cream. Cream is the best source Cream and cod 
of fat for the infant and is to be preferred to codliver oil. If lver 01 
cream cannot be borne codliver oil may, however, be found very 
useful ; dose, a teaspoonful two or three times a day. Lime should 
not be supplied as lime water, for the latter, as stated above, does Lime 
not seem to fulfill the desired purpose. As a rule, if raw meat 
juice is given, or if plenty of good milk is used in the preparation 
of the artificial food, the addition of lime phosphates is rarely 
necessary. If lime salts, however^ must be supplied artificially, 
then they can very advantageously be given in the form of the lacto- 
phosphate prepared as follows : 

3 



Lacto-phos- 
phates 



Calcium phosphate, 


12.5 


Lactic acid, 


15.0 


Distilled water, 


330.0 


Sugar of milk, 


630.0 


Tincture aurant q. s., ad., 


1000.0 



M. S. Two to four dessertspoonfuls a day. 

— (Ortner.) 

Or the calcium lacto-phosphate may be given in water as fol- 
lows: 



Calcium lacto-phosphate, 15.0 

Water, 200.0 

M. S. A dessertspoonful three times a day. 

Some very capable clinicians recommend the administration phosphorus 
of phosphorus in this disease; others, again, claim that its admin- 
istration is unnecessary, provided the above dietetic rules are care- 
fully carried out. Nevertheless, good results occasionally accrue 
from phosphorus treatment. The remedy is best given in com- 
bination with codliver oil, according to the following formula: 



5 



Phosphorus, 
Codliver oil, 
M. S. Two teaspoons daily. 



0.01 
100.00 



This mixture contains about % mg. phosphorus to the tea- 
spoonful. 



270 



DISEASES OF METABOLISM 



Hydrotherapy Hydro-therapy, too, has a place in the treatment of rickets. 

Cold applications are dangerous in the fully developed stages of 
the disease. As a prophylactic measure, however, bathing the in- 
fant daily with warm water that is gradually cooled down to 50 - 
F. is exceedingly useful. 

Orthopedics The extremities and the spinal column of the child should be 

protected against the development of deformities by forbidding 
standing and by carrying the child in such a way that no curvature 
of the spine or extremities can develop. The technique of these 
self-evident precautionary measures, as well as the correction of 
the fully developed deformities, belong to the field of Orthopedics 
and Surgery and need not be elaborated upon in this volume. 



OSTEOMALACIA. 



Phosphorus 
and codliver 
oil 



Calcium 



Anemic medi- 
cation 



Atropine 



Osteomalacia is closely related to rickets, and the medicament- 
ous treatment of the two diseases is practically the same. Here the 
combination of phosphorus and codliver oil that has been men- 
tioned above is particularly useful. Inasmuch as this disease 
usually develops in adult life, the dose of phosphorus may be 
larger than in an infant, as much as 4 to 6 mg. of phosphorus be- 
ing administered during the day and continued for months. Some- 
times codliver oil is not well tolerated and then phosphorus in the 
dose of 0.01 gm. may be given in the form of pills or in chocolate- 
coated tablets. Calcium has been frequently recommended in the 
treatment of osteomalacia, and it can do no harm to give these pa- 
tients ten to fifteen grains of a mixture of calcium phosphate in 
capsule several times a day. Inasmuch as many of these patients 
are anemic, the following capsule is useful : 



1-100 gr. (1 mg.) 

2 grs. (0.1 gm.) 

5 grs. (0.3 gm.) 

10 grs. (0.6 gm.) 



3 

Arsenious acid, 

Reduced iron, 

Calcium phosphate, 

Calcium carbonate, 

M. S. One such capsule three times a day. 

A form of treatment that has been warmly recommended re- 
cently is the use of atropine. Its action in osteomalacia is alto- 
gether obscure. The dose should be regulated according to the ap- 
pearance of symptoms of atropine poisoning. It is always well to 
begin with small doses of about one-two-hundredth grain three 
times a day, and gradually to increase the dose until atropine 
symptoms appear, as manifested by dryness of the mouth, dilata- 
tion of the pupils, etc. 



DISEASES OF METABOLISM 



271 



Diet and 

hygiene 



Adrenalin in the strength of 1 :1000 given hypodermically and Adrenalin 
in the dose of 1 c.c. has occasionally produced favorable results in 
osteomalacia. 

The diet in osteomalacia should be arranged according to sim- 
ilar principles as the diet in rachitis, i. e., there should be an abund- 
ance of albuminous and fat food. The state of the digestive ap- 
paratus should be carefully regulated, and ideal conditions as re- 
gards light and air and dwelling should be created. Here, too, dur- 
ing the florid stage of the disease the prevention of deformities and 
contractures must be considered. The orthopedic and surgical 
measures employed are the same as those in rachitis and cannot be 
entered into here. 



DIABETES INSIPIDUS. 



Diabetes insipidus is a name employed loosely to designate a 
variety of symptomatic polyurias that may be due to different 
causes. Provided one is dealing with a simple polyuria not due to 
cardio-vaseular or renal disease, then the possibility of a cerebral 
or spinal origin, or of hysteria, must be seriously taken into con- 
sideration in every case and treatment instituted accordingly. Tn 
view of the fact that a number of syphilitic lesions of the cerebro- 
spinal axis are capable of producing symptomatic polyuria, every 
case of diabetes insipidus that does not yield to the measures to be 
presently described,, should be given the benefit of an energetic 
antiluetic treatment. In such cases very large doses of iodide of 
potash, i. e., as much as two hundred or three hundred grains a 
day, preferably combined with mercury inunctions or hypodermic 
injections of mercury salts, should be given (see Syphilis). 

The treatment of hysterical polyuria, which is often called 
diabetes insipidus, is synonymous with the treatment of hysteria. 
Quite a few cases of so-called diabetes insipidus are on record for 
instance that were cured by hypnotism, others again by carefully 
carried out rest treatment or hydro-therapeutic measures directed 
against the underlying hysterical perversion. 

In view of the fact that most sufferers from diabetes insipidus 
are nervous people, valerian, bromide of potash, camphor, asafetida 
and antipyrin all have a distinct field of usefulness in this disease. 
I have never seen any good results follow the use of atropine or of 
other preparations of belladonna that have been recommended for 
the purpose of "checking the secretion of the kidneys ;" the dryness 
of the mouth, in fact, which atropine produces usually increases the 
thirst and hence favors rather than checks the polyuria. 



Definition 

Symptomatic 
polyurias 



Hysterical 
polyurias 



Valerian 
Bromides 
Asafetida 
Antipyrin 



272 



DISEASES OF METABOLISM 



Ergot 



Galvanization 
of the cervical 
sympathetic 



Reduction 
the liquid 
intake 



of 



Sweating 



Ergot may be used and not infrequently produces good results. 
Its exact mode of action is not understood, but it presumably exer- 
cises its effect upon the blood vessels of the kidney. Its action can 
best be explained as follows : The amount of urine excreted depends 
upon the blood pressure in the glomerules and the more the renal 
arteries become contracted under the influence of ergot the smaller 
the amount of blood that enters the glomerules and the smaller con- 
sequently the flow of urine. 

A measure that is often useful is galvanization of the sympa- 
thetic in the neck, as described under Exophthalmic Goitre. It is 
not impossible that the galvanic current directed from the angle of 
the jaw to the back of the neck into the region of the lower cervical 
vertebrae actually exercises an effect upon the medulla itself which 
may reduce the polyuria. This assumption, however, is difficult 
to prove and the element of suggestion from the electrical treat- 
ment can never be excluded, especially in a disease which is so com- 
monly combined with hysteria. Electricity, however, should be 
given a fair trial. 

The most rational procedure of all is to reduce the liquid in- 
take,* and at the same time to promote the elimination of water 
through other emunctories of the body than the kidney. Drink 
restriction, as a rule, exercises a pronounced effect upon the amount 
of excreted urine, in fact, some cures have been reported from com- 
plete withdrawal of liquids for a period of twenty-four or forty- 
eight hours. This procedure is exceedingly irksome to the patients 
and requires the exercise of much will power. The distressing 
thirst can be counteracted in a measure by smoking, chewing gum 
or swallowing small ice pills. In order to carry out the thirst treat- 
ment properly it is usually necessary to put the patients to bed and 
to treat them as one would an hysteric under restraint. If it is de- 
sired to sweat the patients, pilocarpine may be given to advantage, 
preferably hypodermically in the dose of 0.01 to 0.015, twice daily; 
or the hydro-therapeutic measures for promoting diaphoresis that 
have been fully described under Cardiac Dropsy may be utilized. 



'Preferably combined with salt restriction (see index), 



CHAPTER IV. 

DISEASES OF THE CIRCULATORY APPARATUS 

THE HEART AND ITS MEMBRANES. 

VALVULAR DISEASES OF THE HEART. 

Lesions about the valves of the heart cannot be repaired by Introductory 
any known means. As soon as one or more of the valves become 
narrowed or insufficient certain compensatory processes are set 
in motion that are intended to neutralize the effects of leakage 
or obstruction and in this way to restore normal circulatory con- 
ditions. The object of treatment in valvular lesions of the heart 
is, therefore, to aid the body in maintaining this balance of com- 
pensation, or in restoring it after it has begun to fail. The same 
indications must be met in so-called muscular or "relative" val- 
vular incompetence not due to valve lesions. 

It would merely complicate the understanding of the treat- 
ment of valvular disease if each lesion were discussed separately; 
for the treatment of mitral and tricuspid incompetence and sten- 
osis, on the one hand, and aortic incompetence and stenosis, on the 
other, is identical; pulmonary stenosis and common congenital 
lesions of the heart are to be treated like mitral lesions; 
pulmonary incompetence in its early stage like aortic incompe- 
tence, and later, when venous stasis becomes marked, like mitral 
lesions. 

The later manifestations of the different single and combined 
heart lesions are in most cardinal respects similar; i. e., in nearly 
all cases there is hypertrophy and dilatation of different portions 
of the heart, myocardial and arterial degeneration with changes 
in the blood pressure and ultimately venous stasis and cardiac 
dropsy in different organs. 

From a practical standpoint it is well to distinguish between 
the treatment of well compensated valvular lesions of the heart 
and those in which compensation is broken. 



274 



DISEASES OF THE CIRCULATORY APPARATUS 



Avoidance of 
heart tonics 



General 
indications 



Subjective 
symptoms in 
aortic insuffi- 
ciency require- 
ing special 
treatment 



Brain symp- 
toms and 
vague symp- 
toms 



Opium 



Contra-in- 
dications to 
the use of 
opium 



Dose and ad- 
ministration 



TREATMENT OF COMPENSATED VALVULAR LESIONS OF THE 
HEART. 

The most important rule in the treatment of compensated 
heart lesions is to forego meddlesome interference. It is unfor- 
tunate that, in well compensated valvular lesions, when a mur- 
mur is accidentally discovered recourse is so often had to the rou- 
tine use of heart tonics. 

The chief aim of treatment in compensated heart lesions is, 
(1) to maintain adequate nutrition of the heart muscle that is 
undergoing, or has undergone, compensatory hypertrophy; (2) 
to put the minimum strain upon the heart in order to enable it 
to maintain compensation; (3) to judiciously strengthen the heart 
muscle by various dietetic^ climatic and hydro -therapeutic means, 
using drugs for this purpose very sparingly, and preferably not at 
all. 

Fully compensated aortic insufficiency occasionally forms an 
exception to this rule, for, owing to the peculiar circulatory condi- 
tions that are created in this lesion, even when it is fully com- 
pensated by hypertrophy of the left ventricle, a variety of dis- 
agreeable subjective symptoms are produced about the brain, the 
respiratory apparatus, the heart and the stomach that call for 
special symptomatic treatment. 

On account of the sudden regurgitation of the blood during 
each diastole, ischemia of the brain may be produced, with such 
symptoms as headache, dizziness, irritability, and a general psychic 
state resembling neurasthenia, with occasional fainting spells. At 
the same time dyspnea is not uncommon, produced presumably 
by irritation of branches of the pulmonary plexus and of the vagus 
from direct pressure of the enlarged heart upon these nerves. 

In all these conditions the best remedy is opium; for in 
cerebral ischemia this drug acts in appropriate doses as a tonic 
to the higher nerve centers and produces plethora of the brain 
vessels which successfully counterbalances the anemia produced 
by the aortic insufficiency; at the same time by acting as a nerve 
sedative it relieves the nervous dyspnea discussed above. 

There is one contra-indication to the use of opium or mor- 
phine in aortic insufficiency, and that is derangement of the ex- 
cretory powers of the kidneys. If the latter are diseased opium 
treatment should not be instituted, for otherwise a cumulative 
action due to deficient elimination of opium may be brought about. 
Idiosyncrasies to opium and morphine should, of course, also be 
included in the calculation; hence it is well, in these cases, to 
proceed with caution and to administer small doses in the begin- 
ning in order to study the effect of this drug upon the individual. 
It is best to begin with the hypodermic injection of doses of mor- 



DISEASES OF THE CIRCULATORY APPARATUS 



275 



phine hydrochlorate ; not to excede one-twelfth grain (0.005 gm.) 
gradually increasing the amount if no untoward symptoms appear. 
That it is best not to let the patients know what drug they are 
receiving need hardly be emphasized as otherwise the morphine 
habit may be created. If after a few days it is found that mor- 
phine is tolerated and if the symptoms are relieved by it. then the 
internal administration either of morphine or of opium may be 
begun. Here, powdered opium in doses of from one-third to one 
and one-half grains (0.02 to 0.1 gm.), or laudanum in doses of 
five to twenty drops, may be given. As a tolerance for the drug 
is gradually established larger doses will have to given. 

If the use of opium or its alkaloids is contra-indicated, or if 
the patient develops too great a tolerance for them, bromides 
may be used to advantage for the dyspneic symptoms and quinine 
for the cerebral signs; the former preferably as sodium bromide 
in fifteen or thirty grain doses (1 to 2 gm.) in milk or soda wa- 
ter; the latter as quinine hydrobromate in doses of five to fifteen 
grains (0.3 to 1 gm.), two or three times a day. 

Two other disagreeable subjective symptoms sometimes require 
special treatment in well compensated cases of aortic insufficiency, 
viz., epigastric pain occasionally assuming the character of gas- 
tralgic attacks, and palpitation. The former condition is presum- 
ably a neurosis of the celiac ganglia or of the abdominal sym- 
pathetic produced by the continuous shocks that these nervous 
elements undergo when the abdominal aorta pulsates vio- 
lently. 

The best local treatment both for the epigastric pain and 
the palpitation is the application of cold to the epigastric or 
precordial regions; an ice bag may be applied for an hour, then 
removed for an hour and reapplied for an hour, and this plan 
continued until the distress is relieved. Occasionally the continu- 
ous application of cold by means of a "Leiter coil" for several 
hours is more efficacious. This apparatus consists of a flat coil of 
thin rubber or metal tubes fastened to a piece of cloth or rubber 
that can be shaped to fit the outline of any part of the body. The 
cold water flows, from a pitcher that is elevated about three or 
four feet above the patient, through the Leiter apparatus to a 
pan placed at the foot of the bed. As the caliber of the tubes is 
very small the water flows slowly and the pitcher does not have 
to be filled more than once an hour or so. The flow is started by 
sucking on the lower tube. Earely, heat applied locally by means 
of a hot water bag acts more beneficially than cold. 

Of drugs opium, quinine and bromides are again useful in 
these conditions, the bromides particularly in severe nervous palpi- 
tation. Valerian in the form of quinine valerianate, dose one to 



Bromides and 
quinine 



Epigastric 
pain and palpi- 
tation 



Cold to the 
precordium 
and epigas- 
trium 



Leiter coil 



Heat 



Opium 
Bromides 
Quinine 
Valerian 



276 



DISEASES OF THE CIRCULATORY APPARATUS 



Cocaine in 
gastralgia 



Diet 



No large 
meals 



Avoidance of 

fermenting 

foods 



Extractives 



Albumen-fat 
diet 



three grains (0.5 to 0.15 gm.), is also often useful. In extreme 
cases of gastralgia cocaine may be used. A convenient way to 
administer the drug in this condition is to prepare a five per cent, 
solution, to pour twenty drops of this into about one-third of a 
glass of water and to administer a teaspoonful of this mixture 
every fifteen minutes for four or five doses or until the pain is 
relieved. 

In the treatment of all compensated valvular lesions of the 
heart the diet is of extreme importance. It should be nutritious 
so that the heart muscle can sustain the excessive labor that it 
is forced to perform in order to maintain compensation, it should 
neither irritate the heart nor, by distending or inflating the stom- 
ach and bowels, mechanically interfere with the heart's action. 

The diet should, therefore, incorporate the full complement 
of calories requisite to maintain nutritive equilibrium (see the 
Chapter on Metabolic Disorders). Large meals should, however, 
never be allowed, for a full stomach pushes the diaphragm up- 
wards, interferes with its respiratory excursions, and hence em- 
barrasses the right heart. 

Aside from mechanically interfering with the heart's action 
large meals favor a determination of venous blood to the diges- 
tive viscera and hence impose much labor on the right heart, while 
at the same time setting certain nervous reflexes in motion that 
cause palpitation and irregular cardiac action. Therefore a pa- 
tient with a compensated heart lesion should be instructed to eat 
small meals, at .frequent intervals, rather than two or three large 
meals at long intervals. 

For similar reasons the diet should contain a minimum of 
those articles that cause gaseous distension of the stomach, as 
for instance, cabbage, potatoes, peas, beans, lentils, sauerkraut 
and aerated beverages. Nor should the diet contain any articles 
that can irritate the heart, for stimulation of the heart muscle 
when it is already working excessively is to be strenuously avoid- 
ed; thus all meat extractives (see below ) y condiments and spices, 
tea and coffee should be forbidden. Alcoholic beverages should 
be taken very moderately and tobacco should, preferably, be abso- 
lutely forbidden. 

The diet should therefore consist largely of albuminous and 
fat foods and should contain relatively little of starchy foods. 

An albuminous diet increases the hemoglobin content of the 
blood so that the nutrition of the heart muscle is thereby aided. 
Some discretion should be exercised in advising the kind of al- 
buminous food and its mode of preparation. Kaw, rare, smoked 
and cured meats, as well as all internal organs like liver, sweet- 
breads, kidneys, etc., should be forbidden, or at least greatly re- 



DISEASES OP THE CIRCULATORY APPARATUS 



277 



Fats 



stricted, because they are rich in extractives, and the latter (con- 
sisting largely of purin bases and their congeners), notoriously 
irritate the heart and increase the blood pressure. For the same 
reason bouillons and meat extracts should be tabooed, for they 
are practically a solution of these extractives. All other meat 
preparations, all vegetable albumens and milk, are very useful 
sources of readily digestible albumen. 

Fats, in the form of butter, cream, olive oil, a little bacon, 
mayonnaise, etc., are valuable adjuvants to the diet, for they 
possess a high nutritive value (1 gm. of fat develops nine cal- 
ories) and at the same time soon produce a sense of satiety and 
hence prevent the patient from overloading the stomach. Fresh 
or stewed fruits and green vegetables fulfill a similar purpose and 
also act beneficially by counteracting constipation. 

The use of bread, potatoes, pastry, cereals, rice, sweets and Carbohydrates 
other carbohydrates should be reduced to the minimum compatible 
with maintenance of the appetite and the enjoyment of food, for 
starchy and sweet foods are apt to produce flatulency and if taken 
abundantly cause engorgement of the liver and consequently im- 
pose added labor upon the right heart, which, above all, should 
be spared in valvular lesions, for the right ventricle is by structure 
less fitted to undergo compensatory muscular hypertrophy than 
the left ventricle. 

One of the most beneficial dietetic means of treating compen- 
sated valvular lesions of the heart is to reduce the liquid intake. 
For in this way the heart and arteries are relieved of much labor, 
the stomach is not so apt to become distended, the blood becomes 
more concentrated and hence acquires more hemoglobin to the 
unit, and the weight of the body is reduced. 

Various theories have been advanced to explain these phe- 
nomena, but none of them as yet offers a convincing explanation. 
Practical experience demonstrates clearly, however, that drink 
restriction generally produces good results both in compensated 
and in decompensated valvular lesions of the heart. Oertel, who 
originated, or, better, revived the method of drink restriction in 
heart disease, presupposed the existence of an hypdremic plethora, 
i. e., an increase of the volume of the blood, especially in cases of 
failing compensation, which could only be corrected by reducing 
the amount of liquid ingesta and at the same time favoring the 
elimination of water by the various emunctories of the body. Ex- 
act determinations of the specific gravity and the freezing point 
of the blood have not borne out this postulate. So much is clear, 
however, that all of the water that is introduced into the stomach 
must needs pass several times through the heart and arteries be- 
fore it leaves the body by the lungs, the kidneys and the skin, 



Reduction of 
liquids 



Oertel's ex- 
planation 



Mechanical 
explanation 



278 



DISEASES OF THE CIRCULATORY APPARATUS 



Determination 
of water 
equilibrium 



Technique of 
drink restric- 
tion 



Fasting 



Reduction of 
common salt 



Rest and ex- 
ercise 



or becomes deposited in the tissues; and it is self-evident that this 
labor can be reduced by giving less liquid and that consequently 
the heart is thereby spared. For this reason drink restriction con- 
stitutes a very valuable prophylactic measure, and also has a place, 
subordinate, it is true, to other more energetic means in the treat- 
ment of decompensated heart lesions. 

It is frequently important to determine whether a disturbance 
of the water equilibrium has already occurred, and this can best 
be done by measuring, for several consecutive periods of twenty- 
four hours, the water intake and output. If it is found that the 
excretion of water is far below the intake and if ? above all, the 
patient during the period of observation gains several pounds in 
weight, then one is justified in assuming that retention of water 
is taking place, that, in other words, the heart and arteries are 
beginning to fail in their task of pumping the water to the emunc- 
tories of the body. When this occurs the patients should be in- 
structed to reduce their liquid intake to about one to one and one- 
half litres of water or other fluids in the twenty-four hours. This 
restriction is frequently borne with difficulty, but most patients 
soon become accustomed to it, especially if the importance of the 
measure is explained to them. That more water should be allowed 
in summer than in winter is clear, for the loss of water via the 
sweat glands must be compensated; or if there is diarrhea or 
emesis the loss of water from the bowels or the stomach should 
also be replaced. 

In extreme cases in which compensation threatens to fail the 
water intake should be still further reduced. Occasionally it is a 
good plan to impose a complete fast for twenty-four or forty-eight 
hours. It will be found that when solid foods are withdrawn the 
craving for liquids is simultaneously reduced; for a fasting indi- 
vidual, even when allowed to drink water without restraint, will 
rarely take more than one litre in twenty-four hours. This is, of 
course, a heroic plan to be employed only in emergencies, but it 
will often be found of inestimable value. That the diet should 
contain as little sodium chloride (common salt) as possible need 
hardly be emphasized in this connection; for the ingestion of 
sodium chloride requires the ingestion of water to hold it in prop- 
er molecular concentration in the blood and hence, as is well 
known, produces thirst. That the amount of water drinking must 
also be governed somewhat by the presence or absence of compli- 
cating diseases, e. g., certain renal and metabolic disorders, fever, 
etc., need hardly be emphasized. 

In all valvular lesions of the heart the regulation of rest and 
exercise is of extreme importance. It is a well known fact that 
many cases of heart disease, with threatening decompensation, 



DISEASES OF THE CIRCULATORY APPARATUS 279 

recover completely when placed at rest without further treatment. 
In cases of valvular trouble without compensatory disturbances, 
complete rest in bed is, of course, unnecessary, but certain simple 
rules should nevertheless be adhered to in order to avoid over- 
taxation of the heart. Thus such patients should avoid moving Rest after 
about for an hour or more after meals, especially if they cannot mea s 
adopt the plan of eating small quantities at frequent intervals; 
for after a heavy meal nearly two-thirds of the total blood col- 
lects in the abdominal veins, and it is manifestly a precarious pro- 
cedure in valvular disease to force all this blood through the right 
heart towards the periphery, an event that will invariably occur 
if muscular exercise is indulged in during the period of diges- 
tion. Exercise after a full meal generally produces a rise in 
arterial pressure and venous congestion in the lesser circulation, 
and this is to be avoided. 

The occurrence of dyspnea and of precordial distress after Terrain cure 
exercise is always a danger signal and the patients should be care- 
fully instructed never to exert themselves to this point. In cases 
of compensated valvular lesions, and this applies also to cases 
in which the balance of compensation is not quite established, the Schott treat- 
so-called Terrain cure, i. e., graduated exercises on measured in- ment 
clined paths, and the Schott exercise treatment* are frequently 
useful. They can best be carried out in certain resorts, chiefly 
Naulieim, where all arrangements for these treatments as well as 
skilled attendants can be found. 

Swedish massage, a plan of treatment that can be pursued Swedish mas- 
at home, is of great value in the treatment of compensated heart sage 
lesions. It consists in a series of resistance exercises that must 
be regulated according to each individual case and should be car- 
ried out by an expert masseur. Some cases, owing to individual 
peculiarities that we do not understand, cannot bear these resist- General mas- 
ance exercises; it is well, therefore, to avoid all routine and to sage 
carefully study the reaction of the individual patient before ad- 
vising the continued use of exercise treatment. All passive exer- 
cise treatment acts beneficially by facilitating the flow of venous Massage of 
blood from the periphery to the • right heart, by reducing the heart 



*The Schott treatment is a combination of passive and active and 
resisting exercises of the trunk and extremities. The cardinal rules 
laid down by Schott for carrying out his treatment are the following: 
"1. The exercise should be performed slowly, steadily and without exer- 
tion. 2. The same movements should never be performed twice in suc- 
cession. 3. Each movement should exercise a different group of mus- 
cles. 4. The patient should rest after each exercise. 5. The pulse and 
breathing should be constantly controlled by the physician." The exer- 
cises should be performed for about half an hour in the morning and 
for twenty minutes in the afternoon, including pauses. If symptoms 
of stasis or stenocardiac attacks appear, the exercises must be stopped. 



280 



DISEASES OF THE CIRCULATORY APPARATUS 



Out door life 



Climate 



Altitude 



Hot and cold 
climates 



peripheral blood pressure, increasing respiration, and by all these 
effects aiding the right heart. 

General massage is always useful for it, too, facilitates the 
back flow of the peripheral blood towards the right heart and 
unless carried out too vigorously, reduces the arterial blood pres- 
sure and thus spares the heart. Massage of the heart itself has 
also been recommended but, unless carried out by an expert, this 
practice is altogether useless and may become dangerous. 

All exercise treatment should be carried out for a long time 
if any real benefits are to accrue. The patients with compensated 
heart lesions should endeavor to live as much as possible out of 
doors; for the breathing of abundant oxygen, by promoting full 
aeration of the blood, will exercise a beneficent effect upon the 
nutrition of the heart muscle. 

Here the selection of a suitable climate must be arranged. 
Four elements must be considered in selecting a resort for a case 
of valvular disease, viz., altitude, the mean temperature, the tem- 
perature variations, and the humidity. 

The decrease of the barometric pressure at an altitude favors 
elimination of water and gases from the surfaces of the body and 
from the lungs, and stimulates an increase of the number of red 
blood corpuscles and of the total hemoglobin, hence increases 
respirations, exaggerates metabolism and improves the nutrition 
of the heart while, at the same time, increasing its labor. By 
sending patients to moderate altitudes this effect can be utilized 
to advantage as a mild stimulant and hence an exercise for the 
heart; but the great altitudes must be avoided for fear of 
overworking the heart and breaking the balance of compensation. 
Patients with heart disease^ therefore, should be warned against 
altitudes over three thousand feet, and if no decompensation 
whatever is present, should be advised to live at an altitude be- 
tween fifteen hundred and two thousand feet above sea level. If 
compensation threatens to fail^ the patient should at once be 
removed from the altitude back to sea level. 

Extreme degrees of heat and cold should always be avoided 
in heart disease. Heat is always bad, for it exercises a depress- 
ing effect upon the whole organism, including the heart. Ex- 
treme cold, on the other hand, both by producing contraction 
of the peripheral arteries and by direct nervous influence upon 
the heart, raises the blood pressure and stimulates the heart to 
greatly increased activity that may fatigue the organ if its valves 
are diseased. Inasmuch, however, as it is easier by proper clothing 
to protect the body from the effect of cold than from the effect 
of heat, a cold climate, other things being equal, is less dangerous 
for a case of valvular disease of the heart than a hot one. Best 



DISEASES OF THE CIRCULATORY APPARATUS 



281 



of all, of course, is a temperate climate with slight temperature 
variations and no extreme degrees of heat or cold. 

The humidity must, finally, also be considered in selecting a Humidity 
resort for a heart case. A dry, warm climate is always to be pre- 
ferred to a moist, warm climate; for, when the air is dry, insensi- 
ble perspiration enables the organism better to counteract the 
depressing effects of great heat than if the atmosphere is moist; 
and a dry, cold climate is more beneficial than a moist, cold cli- 
mate, because in the former there is less radiation of heat than 
in a moist atmosphere so that the body can maintain its tempera- 
ture with less tax upon the general metabolism and hence upon 
the cardio-vascular apparatus. 

There is a popular prejudice against bathing in heart dis- Bathing 
ease. Since the principles of hydriatic treatment have been made 
the subject of accurate scientific research, the exact indications 
and contra-indications for warm and cold bathing in heart dis- 
ease are better understood. Very hot baths (100° F. and above), Hot baths 
owing to their depressing effect, are always to be avoided, for 
immersion of the body in hot water, by producing first a sudden 
short contraction followed promptly by a relaxation of the cutane- 
ous vessels, and later a lasting contraction, always taxes the vaso- 
motor center and the heart. In individuals with well compensated 
heart lesions, who are of the neurasthenic type, this practice is 
particularly dangerous because in such subjects the vaso-motor 
centers are already in a state of unstable equilibrium; and in suf- 
ferers from arterio-sclerosis the fragility of the arterial walls 
renders hot bathing most precarious. Cold bathing should also Cold bathing 
be forbidden in any case of heart disease, for the application of 
cold to the surface of the body always produces a severe initial 
shock with a reflex increase of the heart's action and contraction 
of the peripheral arterioles, in other words, high arterial tension, 
and this means a strain and possibly an over-taxation of the heart. Sea bathing 
Sea bathing should therefore, always be forbidden. 

Lukewarm bathing, viz. ? immersion of the body for ten or 
fifteen minutes at a time in water of 90° to 95° F., i. e., slightly 
below the temperature of the body, is a very useful means of 
treatment. The water may be medicated by the addition of four Salt baths 
to five pounds of salt to a bath tub full of water. In Nauheim, 
Kissingen, Marienbad, Franzensbad and other watering places 
baths with carbonated water are given. They can be prepared 
at home as follows: Half a pound of sodium bicarbonate is dis- 
solved in a bath tub full of water (of about 90° F.) and about 
three-quarters of a pound of commercial hydrochloric acid 
slowly added, care being taken that there is always an excess of 
soda. The patient should at first not remain in the tub for 



Lukewarm 
baths 



Carbonated 
baths 



282 



DISEASES OE THE* CIRCULATORY APPARATUS 



Rationale of 
bath tempera- 
tures slightly 
below the 
body tempera- 
ture 



Medicines in 
compensated 
valvular le- 
sions 



longer than five minutes, nor should he be given such a bath in 
the beginning oftener than once every other day. Later the bath 
may be administered daily and for fifteen to twenty minutes at a 
time. The temperature of the water should not be allowed to 
drop below 80° F. After the bath the patient should be dried 
with warm cloths and put to bed for half an hour or an hour, 
with a hot water bottle to his feet. The patient should never 
become dyspneic while in the water; as soon as breathing becomes 
oppressed the bath should be stopped. An electric fan to drive off 
the C0 2 rising from the bath is useful. 

The good effects derived from bathing in lukewarm water can 
be explained in this way: The temperature of the water, being 
slightly below the body temperature, exercises a very mild stimu- 
lation, through the peripheral and vaso-motor nervous system, up- 
on the action of the heart, slowing and at the same time strength- 
ening its beat; the salt or the carbonic acid gas cause some relaxa- 
tion of the peripheral capillaries and hence a decrease in the blood 
pressure. This means that the heart is being gently driven while 
its work is being reduced. Judiciously carried out, this treatment, 
therefore, constitutes an ideal exercise for the heart when its en- 
ergies are beginning to flag. 

The use of medicines in compensated heart lesions is to be 
eschewed. Only rarely should it become necessary to give any 
heart tonic or vaso-dilator, or any of the other remedies that are 
to be presently discussed under the heading of decompensated 
heart lesions ; nor is any special benefit to be derived from the use 
of so-called general tonics. That drugs may occasionally be neces- 
sary to regulate the function of the stomach or the bowel^ or to 
correct an underlying anemia with relative incompetence of the 
heart valves is self-evident. This medicinal treatment will be dis- 
cussed in other chapters. 

Drugs useful in the treatment of certain subjective symptoms 
of compensated aortic insufficiency have been discussed above. 



Rest 



Position in 
bed 



THE TREATMENT OF VALVULAR DISEASES OF THE HEART 
WITH FAILING OR BROKEN COMPENSATION. 

The most important element in the treatment of failing com- 
pensation is absolute rest in bed. In cases of cerebral anemia, 
i. e., chiefly in aortic insufficiency, the horizontal position may 
be the most agreeable to the patients, but, as a rule, they will 
be more comfortable when semi-recumbent or sitting up during 
a part of the day, even if there is some dyspnea; for the blood 
pressure is always lower when the patient is erect or semi-erect 
than when in a horizontal position. It is generally difficult to 
persuade patients in early stages of decompensation to go to bed. 



DISEASES OF THE CIRCULATORY APPARATUS 283 

If the matter is fully explained to them, however, they will usual- 
ly comply with this order. As Brunton puts it, the patient should 
be told, "If you have sprained your ankle, you know perfectly 
well that every movement that you make is likely to keep up 
the mischief. What you must do is to go to bed and keep the 
ankle perfectly quiet. You must give the heart rest just as you 
give rest to the ankle. If you go on walking with the sprained 
ankle, it will become worse and worse, and finally you will be 
unable to do anything with it. If you go on exercising with a 
strained heart, then you will continue to get worse, and in the end 
you must either give it rest or die." Rest in bed to be efficacious 
should be continued for several weeks; the results obtained are fre- 
quently brilliant, and very often one will be able to get along very 
well without the use of any heart tonics or other medication. 

The diet should be essentially the same as in compensated Diet 
lesions of the heart, especially if the patient is put to bed before 
the appearance of dropsies or passive congestion in different or- 
gans. If such complications of broken compensation have already 
made their appearance then the patient should be put, for a time 
at least, upon a diet consisting largely of milk; for milk possesses Milk diet 
a distinct diuretic action and constitutes an ideal food. It should 
be given at frequent intervals, in small quantities, preferably 
in the form of a milk-cream mixture, consisting of a tumbler 
full (i. e., about nine ounces) of a mixture of two-thirds milk 
and one-third cream to which are added two teaspoonfuls of lime 
water. It is rarely advantageous to put these cases upon an exclu- 
sive milk diet for the flooding of the circulatory apparatus with 
water is decidedly harmful. A. little fresh fruit, an egg, or a lit- 
tle meat and some crackers may usually be added with impunity. 

The application of cold continuously or intermittently to the Cold to the 
precordial region is a very valuable adjuvant to treatment and Precordial re " 
should be employed as described under compensated heart lesions. 
If rest and a simple diet and local cold do not restore compensa- 
tion in mild cases within a week or ten days, or if the case comes 
under observation at a time when decompensation is far advanced, Indications 
so that edema and congestion of the lungs, the liver, the kidneys heart tonics 
and other organs are present, then it becomes necessary to use 
heart tonics. 

The heart normally possesses a certain amount of reserve 
force which it utilizes as soon as an excessive strain is thrown 
upon it. It responds, as is well known, to any sudden over- 
taxation by dilatation, a prolongation of the diastole and an 
increased force of the systole. In valvular diseases this reserve 
force is called upon continuously to establish compensation, and 
in order to meet this added requirement hypertrophy, especially 



284 



DISEASES OF THE CIRCULATORY APPARATUS 



Digitalis. 



Dose of digi- 
talis 



Cumulative 
action 



Tolerance and 
susceptibility 



Intoxication 
with digitalis 



"Pure Prin- 
ciples" of 
digitalis 



of the left ventricle, occurs. An ideal heart tonic, therefore, should 
aid the heart in prolonging its diastole and in enforcing its systole 
to the maximum. 

The chief representative of this group of heart tonics is digi- 
talis, for in appropriate doses it possesses precisely this power. 
Its chief effect is exerted upon the ventricles, stimulating them 
to increased contraction so long as the heart muscle is not in an 
advanced stage of degeneration. Digitalis also raises the periph- 
eral blood pressure, partly from its action upon the heart muscle 
and the nerves of the hearty partly from its effect upon the vaso- 
motor centers, which it stimulates to cause contraction of the ves- 
sel walls; at the same time, it slows the action of the heart. Un- 
der the influence of digitalis the nutrition of the heart generally 
improves; this is due to the increased amount of blood sup- 
plied to the heart muscles when the ventricle contracts more ener- 
getically. 

The dose of digitalis is very important, for large amounts of 
the drug frequently produce an effect that is exactly opposite to 
that exercised by small doses, viz., they reduce the force of the 
systolic contractions and in lethal doses cause arrest of the heart 
in diastole. Its action is tardy, as it is slowly absorbed, so that a 
day or two may elapse before the effect of the drug upon the 
heart and the pulse becomes apparent. If the dose is increased 
too rapidly in the beginning (because its effect may not have 
appeared at once) intoxication from cumulative action may occur; 
and as the excretion of digitalis is as slow as its absorption, there 
is also always danger of cumulative action from disturbed excre- 
tion. Some individuals, moreover, seem to possess an idiosyn- 
crasy against digitalis while others show a remarkable tolerance 
to its action. It is therefore always best to begin with small doses, 
and during the first days of its administration to carefully watch 
the heart, the pulse and the blood pressure for signs of digitalis 
poisoning. 

In susceptible subjects digitalis may, when first administered, 
produce disagreeable symptoms of a nervous character, as palpita- 
tion and insomnia, and sometimes symptoms of gastric or intes- 
tinal irritation, as nausea or diarrhea. These signs, however, can 
generally be ignored because they shortly disappear as soon as 
the organism accustoms itself to the drug. It is claimed that 
some of the pure principles of digitalis possess only the cardiac 
action without the disagreeable local or general effects. All these 
principles, however^ according to the best authorities are so un- 
certain in their action and vary so much in strength that their 
use can hardly be recommended excepting tentatively in those 
cases that display an absolute intolerance against digitalis, and 



DISEASES OF THE CIRCULATORY APPARATUS 



285 



these cases are very rare. If no signs of cumulative action or of 
particular susceptibility to the drug appear within the first two 
or three weeks of its employment, then there is no valid objection 
to a continued digitalis therapy, preferably using small doses 
for indefinite periods of time, even years. This practice, if it 
can be carried out, is warmly recommended by many authorities 
and seems to be particularly useful in heart lesions combined with 
chronic arteritis and arterio-sclerosis. • 

Occasionally a case of valvular disease comes under observa- 
tion for the first time with a very slow and intermittent pulse, 
great muscular weakness, gastric and cerebral symptoms; if on 
inquiry it is found that such a patient has been taking digitalis 
for a long time it is always well to tentatively stop or greatly 
reduce the use of the drug in order to rule out the possibility of 
chronic digitalis intoxication. If the heart is alarmingly slow 
one two-hundredth of a grain of atropine, hypodermically, should 
be given until the toxic digitalis effect wears off. 

Digitalis is contra-indicated in any case of failing compensa- 
tion in which the heart muscle has begun to degenerate, especially 
in advanced myocarditis and fatty heart, as here the heart cannot 
react to the drug; in fact, by increasing the blood pressure digi- 
talis may seriously embarrass a heart with a weak musculature 
and cause disagreeable or dangerous complications. For this rea- 
son the drug is less useful in aortic insufficiency than in other, 
especially mitral, valvular diseases, because aortic insufficiency 
rarely becomes decompensated until extensive degeneration of the 
left ventricle has occurred. This is due to the fact that the walls 
of the left ventricle are capable of undergoing enormous hyper- 
trophy before they begin to fail, whereas, the right ventricle suc- 
cumbs much sooner to overstrain; as a result mitral lesions and 
lesions of the valves of the right heart produce failure of com- 
pensation much sooner than aortic lesions, and often at a time 
when the walls of the left ventricle are still intact ? capable of 
hypertrophy and susceptible to the action of digitalis. For this 
reason digitalis should be given with the greatest care in diseases 
of the aortic valves and only after the absence of myocarditis has, 
so far as that is possible, been established. In fact, digitalis may 
be used occasionally as a valuable diagnostic aid for detecting 
the presence of myocarditis. For degeneration of the heart mus- 
cle may be assumed if a digitalis effect, i. e., slowing of the 
heart beat, an increase of the pulse-tension and impulse, with a 
forcible apex beat and increased diuresis, do not appear within 
two or three days after the administration of the drug. In such 
cases, of course, it is very bad practice to continue with the use 
of digitalis. 



Continued use 
of digitalis 



Chronic 
digitalis 
poisoning 



Atropin as an 
antidote 



Contra-indi- 
cations 



Care in using 
digitalis in 
aortic disease 



Digitalis in 
the diagnosis 
of myocarditis 



286 



DISEASES OF THE CIRCULATORY APPARATUS 



Digitalis and 
strophanthus 
in atheroma 



Digitalis with 
nitroglycerin 
and nitrates 



Preparations 
of digitalis 



Digitalis by 
rectum and 
hypodermically 



"Pure prin- 
ciples" of digi- 
talis 



Another contra-indication to the use of digitalis is extensive 
atheroma or fragility of the arterial walls, for here the increased 
pressure may lead to rupture of the vessel walls. Strophanthus 
should be the remedy of choice in these cases, because it acts as a 
heart tonic without causing so great a rise of the blood pressure 
as digitalis. If it becomes necessary to give a heart tonic in such 
cases it is best, however, to use digitalis or strophanthus in com- 
bination with drugs like nitroglycerin or nitrites that can lower 
the blood pressure; remembering always that the effect of the ni- 
trites becomes manifest much more rapidly than the effect of digi- 
talis, so that the nitrites should be given several hours after the 
digitalis ; and that the effect of nitroglycerin is very short so that it 
should be given in frequently repeated small doses, several hours 
after the digitalis has been taken. 

Of the many preparations of digitalis, the infusion and the 
tincture are, from a practical point of view, at least, the best. 
The infusion made from the leaves (that should preferably be 
cut into small pieces and not powdered) should always be fresh. 
It should be given in doses of from one to two fluid drachms (4 
to 8 cc.) according to the requirements of the case. The alco- 
holic tincture of digitalis is of more uncertain composition and 
strength than the infusion; nevertheless, in the great majority of 
cases, it will be found to be efficacious. The proper dose is from 
five to fifteen drops (0.3 to 1 cc.) three times a day. 

Occasionally it becomes necessary in patients who do not re- 
act properly to the infusion or tincture to give digitalis in the 
form, of the powdered leaves in doses from one to four grains 
(0.5 to 0.2 gm.), either in a capsule with sugar of milk or in a 
pill. This preparation, however, often produces irritation of the 
stomach, which is especially the case among patients with venous 
stasis in the gastric veins due to heart disease, i. e., with conges- 
tive catarrh of the stomach. Here small quantities of the in- 
fusion, diluted with milk and administered ice cold, are frequently 
well borne. 

When the stomach will not tolerate digitalis the drug may be 
administered in the form of an enema and the infusion can be 
used for this purpose. Such a clysma, preceded by a cleansing 
enema, may be given two or three times a day. Occasionally the 
administration of digitalis leaves in suppositories fulfills a use- 
ful purpose. The hypodermic administration of digitalis is usu- 
ally very disagreeable, because digitalis exercises a local irritant 
action and the injection of the drug under the skin is usually 
painful. 

The chief glucosides of digitalis, viz., digitoxin, digitophyllin, 
digitalin and digitaline are all extensively used and abundant 



DISEASES OF THE CIRCULATORY APPARATUS 



287 



literature has appeared on the subject. So far, however, I have 
found it unnecessary, in the great majority of cases, to have re- 
course to these preparations^ especially as their strength and ef- 
ficacy are usually uncertain; and, old fashioned as it may ap- 
pear, I give the infusion of digitalis, described above, and the 
powdered leaves the preference over all other digitalis preparations. 

The effect of digitalis may occasionally be enforced by re- 
stricting the liquid intake or by sweating, or both. Alcohol, 
given half an hour before the digitalis, also makes the latter more 
effective. 

Brief mention may be made of certain other heart tonics 
that should occasionally be used, either if digitalis is not well 
borne by the patient or if a cumulative effect appears; the most 
useful among these in my experience are strophanthus, conval- 
laria, adonis vernalis and caffein. 

Strophanthus, like digitalis, strengthens the action of the heart Strophanthus 
muscle and slows the pulse, it also raises the arterial blood pres- 
sure, but not to the same degree as digitalis, nor does it possess 
the same diuretic strength. It may, therefore, be used to advan- 
tage in place of digitalis in cases of valvular heart disease with 
arteritis. The chief advantage it possesses over digitalis is that it 
does not have a cumulative action, so that this drug can always 
be continued with safety for long periods of time. It seems that 
strophanthus is more irritating to the kidneys,, however, than 
digitalis, so that, in cases of cardiac disease complicated with 
nephritis, especially in Bright's disease, the drug should be ad- 
ministered with care. The best mode of administering strophan- 
thus is in the form of the tincture, in doses of five to fifteen drops, 
three or four times a day. It may also be given in the form of 
strophanthin, hypodermically, in doses of one one-hundred-and- 
fiftieth to one-fiftieth of a grain (0.0004 to 0.0012 gm.). 

Convallaria retards the heart's action, increases the arterial 
tension and possesses some diuretic power. It is not cumulative 
in its action and never irritates the stomach; occasionally it even 
seems to stimulate the appetite. Convallaria is usually given in 
the form of the alcoholic tincture (five to ten drops) or the fresh 
watery extract (four to eight drops). 

Adonis vernalis increases the arterial pressure, strengthens 
and slows the heart beat. On account of its great blood pres- 
sure raising power it acts very well as a diuretic when the kid- 
neys are inactive and it is especially useful, therefore, in cardiac 
dropsy. In cases of interstitial nephritis, however, in which the 
blood pressure is already high, or in arterio-sclerosis complicated 
with heart lesions, the drug should be used with great care. It is 



Convallaria 



Adonis ver- 
nalis 



288 



DISEASES OP THE CIRCULATORY APPARATUS 



Caffein 



best given in the form of the fresh infusion, one to four drachms 
(4 to 16 cc.). 

Caffein strengthens the heart muscle, raises the peripheral 
blood pressure and increases diuresis, not, however, by its blood 
pressure raising power but by a specific action upon the renal epi- 
thelium. This drug, too, should never be given when the periph- 
eral blood pressure is high, nor should it be given to very excitable 
individuals, nor to alcoholics on account of its well known action 
upon the higher cerebral centers. It not infrequently produces 
insomnia, and occasionally hallucinations and delirium. It is 
particularly valuable as a substitute for digitalis and the other 
heart tonics that exercise their effect directly upon the heart 
muscle, in eases in which the latter is beginning to degenerate, 
because caffein presumably manifests its effect not upon the 
heart muscle directly but upon the nervous apparatus governing 
the heart beat. 

The best preparation is caffein citrate, which may be given in 
doses of two to eight grains (0.1 to 0.5 gin.), or caffein may be 
administered hypodermically in combination with sodium salicy- 
late or benzoate, the latter salts forming double compounds with 
caffein and preventing its decomposition with water. 

The drug should be given two or three times a day in the fol- 
lowing solution : 



Theobromin 



Strychnia 



y 



Salicylate of soda, 


30 gm. 


Caffein, 


40 gm. 


Water, 


60 cc. 


M. 




Dose for hypodermic use, ten drops ; 


or 


Caffein, 


2.5 gm. 


Sodium benzoate, 


3.0 gm. 


Distilled water, 


10 cc. 


M. Sig. 1 cc. hypodermically. 






— (Tanret.) 



Of this solution each cubic centimeter contains four grains 
(0.25 gm.) of caffein. 

Theobromin, in capsule, in doses of eight grains (0.5 gm.) 
three times a day, or in solution with a little salicylate of soda; 
or diuretin, in the same dose; may also be given in place of caffein 
or its citrate. 

Strychnia may also occasionally be used in small doses, one- 
hundredth to one-thirtieth grain (0.0006 to 0.002 gm.) to slow 



DISEASES OF THE CIRCULATORY APPARATUS 



289 



the heart and raise the blood pressure in failing compensation; 
it acts chiefly upon the vaso-motor center in the medulla and the 
general nervous system. It slows the heart beat by its stimulating 
effect upon the inhibitory center. It should never be used as a 
heart tonic when the arterial tension is high. 

In extreme cases of cardiac failure in which no time is given Analeptics 
to gradually strengthen the heart by the use of heart tonics, it 
becomes necessary to have recourse to analeptics, as an emer- 
gency measure. The clinical indications for the use of these reme- 
dies are a weak apex beat, a feeble heart action, a great reduction in 
the force of the radial pulse or its complete disappearance, cold- 
ness and lividity of the extremities and collapse. 

The best analeptic we possess is adrenalin. In acute and dan- 
gerous disturbances of the heart and the respiration, in collapse 
following narcosis or surgical shock, in hemorrhages and in perito- 
nitis the injection directly into the vein of 1.2 to 1 cc. of the 
ordinary 0.01 per cent, solution of adrenalin is the most efficient 
remedy. Other analeptics are camphor, ether and ammonia. 

In cardiac failure, brandy or champagne and hot coffee may 
be administered, but camphor is the remedy par excellence, either 
alone or as spirits of camphor twenty to thirty drops, or in com- 
bination with digitalis, thus : 



Camphor 

Ether 

Ammonia 

Brandy 

Champagne 

Coffee 



E 



Camphor, 

Powdered digitalis leaves, 



1 gr. (0.05 gm.) 

2 gr. (0.1 gm.) 



For it possesses the power to excite the nervous system and to 
rapidly produce acceleration and increased strength of the heart's 
action. In an emergency camphor may be given hypodermically 
in 10 per cent, solution in ether or in sterile olive oil, twenty to 
thirty drops at a time. 

Ether, or "Hoffman's anodyne" (Spir. etheris comp.) 7 a tea- 
spoonful on sugar, or ether alone, hypodermically, are also use- 
ful. Ether acts still more rapidlv than camphor, and whenever P hor . and am - 
it is desired to produce a very quick effect, ether should first be 
given and an injection of camphorated oil (see above) after- 
wards ; or camphorated oil in ether, one part of ether to two of 
the oil, may be administered in the dose of two or three hypodermic 
syringes. 

Ammonia, in the form of the aromatic spirits of ammonia, in 
the dose of fifteen to sixty minims (1 to 4 cc), frequently repeated 
may also be employed. 



Indications for 
the use of 
ether and cam- 



monia 



290 



DISEASES OF THE CIRCULATORY APPARATUS 



Insomnia 

Irritability 

Psychoses 



Cheyne-Stokes 
breathing 



Stupor and 
somnolence 



Treatment of 
insomnia 



Dangers of 
chloral and 
opium 



Bromides 



SYMPTOMATIC TREATMENT OF STASIS IN DIFFERENT OR- 
GANS DUE TO DECOMPENSATED VALVULAR LESIONS. 

In advanced degrees of failing compensation venous stasis oc- 
curs in different organs of the body; and while the treatment 
of the symptoms produced by this passive congestion, notably in 
the brain, the lungs, the liver, the kidneys and the gastrointes- 
tinal tract, is essentially synonymous with treatment directed 
towards improving the general heart action, as described in pre- 
vious paragraphs, it occasionally becomes necessary, in addition, to 
relieve some of the most urgent symptoms that follow the con- 
gestion of these parts of the body. 

Passive Hyperemia of the Brain. Passive hyperemia of the 
brain is one of the most frequent and one of the most distress- 
ing consequences of broken compensation. In mild degrees the 
chief symptoms are insomnia and general irritability, occasional- 
ly assuming thei characteristics of monomanias or of other psy- 
choses. As the medulla is, at the same time, usually in a state 
of congestion, respiration may become irregular and the Cheyne- 
Stokes type of breathing be produced. In late stages of failing 
compensation chronic venous congestion of the brain produces 
stupor and somnolence. 

If these symptoms do not readily yield to cardio-tonic medi- 
cation, then recourse must be had to remedies that control the 
nervous phenomena, especially the insomnia. In selecting reme- 
dies for this purpose among the numerous hypnotics and nar- 
cotics that we possess, the impaired condition of the heart must 
always be taken into consideration. For this reason chloral, 
which is deservedly one of the most popular hypnotics, cannot 
be used, for chloral exercises a depressing effect upon the car- 
diac muscle and the muscles of the blood vessels and also pro- 
duces paresis of the vaso-motor centers. It acts, in this respect, 
similarly to chloroform. Moreover, chloral is particularly contra- 
indicated in this form of insomnia because it produces congestion 
of the peripheral organs, including the brain, and this is precisely 
what we are attempting to counteract. The same objection ap- 
plies to the use of opium and its alkaloids, for they too reduce 
the tone of the vaso-motor centers and the peripheral blood pres- 
sure, thus causing dilatation of the blood vessels and cerebral 
congestion. 

The most useful drugs in the treatment of this form of in- 
somnia are the bromides, for they quiet the sensibility of the 
whole nervous system, and in particular of the special senses, 
and hence enable the patient to go to sleep, simply because external 
influences cannot stimulate the over-irritable brain. It has been 
claimed, moreover, that the bromides produce a distinct anemia 



DISEASES OF THE CIRCULATORY APPARATUS 



291 



of the brain, and that this property can be used to counteract 
congestion. As a matter of fact, it has been shown by recent 
investigations that the anemia of the brain found in animals that 
were killed after having taken large doses of bromides, is no 
more intense than that found in animals killed when they were 
asleep; so that the cerebral anemia observed after the administra- 
tion of bromides must be considered due to the sleep, and the sleep 
not due to the cerebral anemia. 



Bromide of 
potash 



Bromide of 
soda 



The bromide of potassium should never be given in cerebral 
congestion due to valvular heart lesions, because large doses of 
potassium undoubtedly weaken the heart and reduce the blood 
pressure. The bromide of sodium produces less gastric irritation 
than the bromide of potassium; this drug should therefore be 
given, preferably in milk and in two divided doses of fifteen 
grains each, the one about three hours before retiring and the 
other just before going to bed. It will be found that after a few 
days' treatment the patients will react more rapidly to smaller 
doses than in the beginning. 

Next in importance to the bromides are sulphonal and its Sulphonal 
congener, paraldehyde, and a group of drugs that are related to 
chloral but do not possess the depressing action of this remedy 
upon the heart, viz., chloralamid, chloralose, chloretone, and 
veronal. 

The continued use of sulphonal, however^ is fraught with 
some danger and it should be employed with care in heart cases; 
moreover, it does not seem to act as energetically in cases of 
failing compensation as otherwise. In giving sulphonal the urine 
should be carefully inspected. If it assumes a peculiar burgundy- 
red color the administration of the drug should immediately be 
stopped, for sulphonal, in persons who possess a peculiar idiosyn- 
crasy to the drug, occasionally produces hematoporhyrinuria.* It 
should be given in doses of from fifteen to thirty grains (1 to 2 
gm.), in some hot beverage, about three or four hours before go- 
ing to bed. As sulphonal is excreted very slowly it will be found 
that the dose can gradually be reduced. 

Trional acts more rapidly than sulphonal, and usually pro- 
duces sleep within an hour. It is given in the same dose as sul- 
phonal, and is particularly efficacious if given in combination with 
codeine, one-fourth grain (0.015 gm.). 

Paraldehyde does not influence the heart in any way and pro- 
duces a very rapid hypnotic effect, the patient usually going to 
sleep within ten or fifteen minutes. The drug should be given in 
doses of fifteen to sixty minims (1 to 4 cc), preferably in brandy 



Trional 



Paraldehyde 



♦See Tyson and Croftan: Trans. Ass'n. Am. Phys. 1901. 



292 



DISEASES OF THE CIRCULATORY APPARATUS 



Chloretone 



and water. As the drug is largely excreted through the lungs, the 
patients for a day after the use of paraldehyde are apt to com- 
plain of a disagreeable odor of the breath, similar to alcohol. 

Chloralamid Chloralamid is a compound of chloral and formamide and de- 

composes in the stomach with the liberation of formamide, a drug 
that counteracts the circulatory depression produced by chloral. Its 
hypnotic effect is very marked. Dose, fifteen to thirty grains 
(1 to 2 gm.). 

Chloralose Chloralose, a glucoside compound of chloral, does not affect 

the heart at all and is an excellent hypnotic. It should be given 
in powder form in capsules containing two to five grains (0.12 to 
0.3 gm.) of the drug. This dose may be increased to two oi 
three powders on succeeding days, if the desired effect is not 
produced by one powder. 

Chloretone does not irritate the stomach, especially in watery 
solution, nor does it depress the circulation. It usually produces 
a marked effect in small doses of five to ten grains (0.3 to 0.65 
gm.) and may be used as an alternative for some of the other 
remedies. 

Veronal Veronal, finally, is one of the most useful newer hypnotics 

in cerebral congestion. It acts exclusively upon the central ner- 
vous system, does not depress the heart or circulation, and leaves 
very slight after-effects. It may be given in doses of five to fifteen 
grains (0.3 to 1 gm.) in warm water or milk, or in capsule, about 
an hour and a half to two hours before sleep is to be produced. 

Of all the other commoner hypnotics that might be used can- 
nabis indica is mentioned merely to be condemned, for it exercises 
a very deleterious effect upon the heart and circulation and 
should never be used in sufferers from valvular disease. 

In addition to all these hypnotic and narcotic remedies, blood- 
letting, either locally or by venesection, is an exceedingly useful 
measure for combating cerebral hyperemia. Blood may be with- 
drawn locally, either by the use of leeches or by scarification and 
cupping. As the latter procedure cannot be applied in blood- 
letting about the skull, the technique will not be described in this 
place. Leeches should be applied in cerebral congestion to the 
mastoid process. 

Good leeches should move about freely in water and should 
contract when touched. To induce the leech to take hold a drop 
of sugar solution or of milk is placed upon the skin, or, better 

Leeches still, a small incision is made so that a drop of blood oozes out. 

The skin, of course, should be thoroughly cleansed before the leech 
is applied. As a rule, the leech is allowed to suck blood until it 
lets go spontaneously. If it is desired to remove the leech before 
he has sucked all the blood he can, a little salt may be put upon 



Cannabis indica 



Bloodletting 






DISEASES OF THE CIRCULATORY APPARATUS 293 

his tail. If, on the other hand, it is desired to prolong the bleed- 
ing after the leech has let go, the wound may be treated with a 
warm sterile solution of salicylic acid. 

The artificial leech is much more elegant and doubtless is as 
efficacious for local results. 

Venesection usually produces a much more rapid effect and is Venesection 
particularly useful in venous hyperemia of the brain due to val- 
vular disease. By withdrawing enough blood from a vein the 
heart is at once relieved of a great deal of labor, and resumes, for 
the time at least, its normal action, especially if venesection is 
enforced by cardio-tonic medication. Venesection is performed 
as follows: The arm is compressed above the elbow with a hand- 
kerchief or a bandage, so that one of the three large veins on the 
anterior surface of the fore-arm becomes prominent; the skin is 
carefully disinfected over the place of incision and the scalpel in- 
troduced with the cutting edge forward into the vein. The cut 
should be made diagonally across the vein for by doing so both the 
circular and longitudinal muscle fibers of the blood vessel wall 
are severed, and closure of the incision is thereby facilitated and 
accelerated. About 3 cc. of blood to each kilo of body weight 
should be withdrawn, not more. After the desired amount of 
blood has been allowed to escape the constricting binder is removed 
and the wound tied up with a small pressure bandage. If the pa- 
tient should faint during venesection, bleeding should immediate- 
ly be stopped and the patient placed in a recumbent position, with 
the head lowered. If the subject is very fat it may be necessary 
to dissect down to the vein, a little operation that can readily be 
performed under local anesthesia. Occasionally the median cuta- 
neous nerve is severed during this operation, producing a little 
pain or tingling along the distribution of this nerve; these symp- 
toms usually disappear within a day or two. Particular care 
should, of course, be taken neither to wound the posterior wall of 
the vein nor to sever the artery, and it is always well first to de- 
termine the position of the artery and to select that vein for in- 
cision which is farthest removed from it. Puncture of a vein 
with a trocar may also be performed but this procedure is not 
quite so safe. 

Passive Hyperemia of the Lungs. Passive hyperemia of the Passive hy- 
lungs due to valvular disease is very common. As a rule the j^ngs 
dyspnea, the bronchitis and the hemoptysis readily disappear if 
the heart is treated. Occasionally, however, the congestion of 
the bronchial mucosa becomes chronic and a bronchial catarrh is 
produced that may call for special attention. Here the same rem- Cardio-tonic 
edies are useful) as in other forms of bronchitis, so that I refer 
for the special treatment of this complication to the Chapter on 



294 



DISEASES OF THE CIRCULATORY APPARATUS 



Danger of 
opium 

Tartar emetic 

Ipecac 



Ammonium 
chloride 

Tolu 

Benzoin 



Syrup of 
squills 



Venesection 



Epigastric pain 

Gastro-intesti- 
nal disorders 



Diseases of the Respiratory Organs. In heart disease, however, 
certain of our most popular expectorants become dangerous on 
account of their effect upon the heart; thus tartar emetic and 
apomorphine should never be used in these causes. Opium, mor- 
phine and ipecac should also be given with very great care. The 
former, because they produce congestion and thereby merely ag- 
gravate the pulmonary hyperemia; the latter, because it may pro- 
duce vomiting and in this way severely strain the cerebral vessels 
which are congested, and hence may possibly produce cerebral 
hemorrhage. If the catarrh of the bronchial mucosa is dry and 
the secretions are expelled with difficulty, ammonium chloride or 
some of the preparations of benzoin, as syrup of tolu or com- 
pound tincture of benzoin, thirty minims to two fluid drachms (2 
to 8 cc.) may be given. Codeine or heroin in one-sixteenth to one- 
eighth grain doses (0.004 to 0.008 gm.), repeated, are very use- 
ful in this condition especially for allaying excessive irritation and 
reducing the cough. The syrup of squills is particularly valuable, 
for scilla being a member of the digitalis series, possesses a marked 
cardio-tonic effect; and hence it not only increases the bronchial 
excretion, promotes better expectoration and relieves the cough, 
but also supports and stimulates the heart. It may be given con- 
veniently in the form of the syrup of squills in the dose of thirty 
to forty minims (2 to 3 cc). 

In pulmonary and bronchial congestion venesection is again 
a sovereign remedy; in fact, occasionally, spontaneous bleeding 
from the lungs is Nature's way of relieving the hyperemia. The 
treatment of this hemoptysis if it should become severe is chiefly 
cardio-tonic. Ergot, of all remedies, should never be given (see 
Hemoptysis). 

Passive Hyperemia of the Liver. In valvular diseases of the 
heart, with failing compensation, passive congestion of the liver 
is particularly liable to occur. First,, because the hepatic veins 
are so near the heart, so that any interference with the entrance 
of the blood into the right auricle readily becomes manifest in the 
liver veins; second, because the pressure within the liver veins is 
naturally very low. For this reason we often encounter cases of 
valvular disease with only slight disturbances of compensation in 
which the liver is the first and only organ afflicted with passive 
hyperemia. Some of these patients actually complain of no symp- 
toms about the heart, and suffer merely from pain in the epigas- 
trium, a feeling of heaviness or pressure in the hepatic region, 
and gastro-intestinal disorders, all resulting from the impaired cir- 
culation in the liver and the enlargement of the organ. 

The treatment here, as in other conditions of passive hypere- 
mia due to valvular diseases is primarily cardio-tonic. In addi- 



DISEASES OE THE CIRCULATORY APPARATUS 



295 



.Counter irrita- 
tion over the 
liver 

Cupping 



Ice bag 



tion, however, it may become necessary to institute certain spe- 
cial treatment in order to relieve the symptoms just described. 

Chief among these is counter-irritation over the liver, either 
by means of vesication, leeching or cupping. The method of ap- 
plying leeches has already been described. Cupping is performed 
as follows : The skin is shaved and thoroughly cleansed. An ordi- 
nary cup or the special apparatus that is constructed for the pur- 
pose, is warmed and placed upon the skin. Owing to the vacuum 
created within the cup the cupped area becomes hyperemic and this 
constitutes an efficient counter irritation. If it is desired to with- 
draw blood by cupping the surface of the skin should be scarified 
and the cup applied as above; in this way several ounces of blood 
can be withdrawn. 

The ice bag also occasionally affords relief, especially if it 
is applied intermittently, i. e., left on for one hour and removed 
for one hour. The ice bag, of course, should never be applied 
directly to the skin, but a few layers of gauze or a handkerchief 
must be placed between the skin and the ice bag. 

In other cases heat is more grateful. Mustard plasters and 
poultices made of bread, linseed, cranberries or oatmeal can also 
be used to apply heat and at the same time to counter-irritate. 
Occasionally it is useful to add some narcotic to the poultice^ and 
this can best be done by dipping a small piece of linen into tinc- 
ture of opium or belladonna and placing it into the material that 
forms the poultice. A very useful method of applying continu- 
ous heat, locally, is to use a thermophor, i. e., an ordinary rub- 
ber bag filled with sodium acetate. By leaving this bag in boil- 
ing water for ten minutes the acetate is dissolved. The thermophor 
is then wrapped in a hot cloth and applied to the surface of the 
body. As the salt crystallizes out again, heat is liberated and, in 
this way, a temperature of from 40° to 50° C. (105° to 122° F.) 
can be maintained for several hours. 

Another method is occasionally used in the treatment of he- Anal leeching 
patic congestion due to cardiac weakness, viz., the withdrawal of 
blood, preferably by leeches, from the anal region. This empirical 
method was first described by Sacharjin, and is useful as well in 
hyperemia of the brain and the spinal cord and in stasis in the 
portal circulation, as in hemorrhoidal conditions. The leeches 
may either be applied to the perineum or to the sacral region. If 
a leech should crawl into the rectum, a solution of common salt 
(2 to 5 per cent.) should be injected in order to kill the animal. 

In passive hyperemia of the liver the alkaline and saline min- 
eral waters are very) useful. Chief among them are the waters 
of Marienbad, Kissingen and Franzensbad. Bitter waters, espe- 
cially Huriyadi-Janos, are also useful. If the kidneys are af- 



Heat 



Plasters and 
poultices 



Thermophor 



Mineral 
waters 



296 



DISEASES OF THE CIRCULATORY APPARATUS 



Diet in passive 
congestion of 
the liver 



Vegetable 
laxatives 



Method of 
giving digi- 
talis 



fected, or if there is much anasarca, the taking of these waters 
is, however, contra-indicated. Cases of hepatic hyperemia are 
usually benefited by a "cure" in Kissingen or Marienbad and 
similar watering places, not only because they drink the waters, 
but also because they are forced to live a more sensible life and 
are placed upon a strict and rational regime. 

The diet should contain very little carbohydrate food, because 
starches and sugars always produce a digestive congestion of the 
liver, an effect that is, above all things to be avoided. For the 
details of the diet in hepatic insufficiency due to stasis, I refer to 
the Chapter on Diseases of the Liver. In cases of passive hypere- 
mia of the liver with renal symptoms, in which the saline and al- 
kaline waters may have to be eschewed, certain vegetable laxatives 
are useful. Chief among them are rhubarb, aloes, podophyllum, 
cascara sagrada. Calomel also has its place in this affection. All 
these remedies are intended to act as laxatives, and their exact ad- 
ministration and dose will be found described in the Section on 
Diseases of the Intestine. 

Passive congestion of the stomach and intestine is a very com- 
mon and a very disagreeable symptom of cardiac weakness. It 
may be due either directly to the interference with the venous 
back-flow from the gastro-intestinal mucosa, or to passive hypere- 
mia in the liver, with resulting stasis in the portal system. In 
many cases the picture presented is that of a gastro-intestinal ca- 
tarrh (occasionally with hematemesis) and the treatment of this 
condition differs in no respect from the ordinary treatment of 
such a catarrh, with this exception, that combined with the usual 
dietetic and medicinal measures employed for its relief, energetic 
cardio-tonic treatment should be simultaneously instituted. Here 
one difficulty is encountered, viz., the danger of giving digitalis by 
mouth, on account of the irritating action that this remedy oc- 
casionally exercises upon the stomach. This objection, however, 
is more theoretically constructed than practically important; for 
only in rare cases do we find the irritability of the stomach so 
great that digitalis cannot be given by mouth. If the infusion of 
digitalis is given in small quantities at a time, and if it is given 
ice cold, difficulties will rarely be encountered. If necessary, digi- 
talis can be given in the form of an enema or in a suppository, or, 
as a last resort, in the form of digitalin, one-sixtieth grain (1 
mg.), hypodermically. 

Passive Hyperemia of the Kidneys. Passive hyperemia of the 
kidneys, finally, aside from cardio-tonic treatment, calls for a 
careful regulation of the diet. It is important to recognize the 
character of the renal difficulty, i. e., to decide whether or not there 
is present a real nephritis or merely stasis in the kidney. The 



DISEASES OF THE CIRCULATORY APPARATUS 297 

presence of valvular lesions and evidence of embarrassment of the 
venous circulation in other organs usually decides the question. 
The urine as a rule is concentrated, owing to a relative increase 
of urea, uric acid and urinary pigments; hence its specific grav- 
ity is high and it has a tendency to precipitate an abundant urate 
sediment. Its color is usually very dark. There is rarely much 
albumin. Hyaline casts, in small numbers, are commonly present, 
also a few leucocytes and an occasional red blood corpuscle. Eenal 
epithelia, granular or blood casts are generally absent.* 

In these cases a milk diet is useful. Too much milk should Milk diet 
not, however, be ordered, nor should large quantities of milk be 
given at a time. The milk diet, by leading to the formation of 
small quantities of irritating urinary end-bodies, spares the kid- 
neys; it also acts to a certain extent as an intestinal antiseptic 
and hence prevents the formation in the bowel of putrefactive 
poisons that can irritate the heart and the kidneys; in addition, 
it possesses diuretic properties which act advantageously by stim- 
ulating the kidneys to an increased secretion of water. The only 
objection to an exclusive milk diet is the danger of flooding the 
cardio-vascular apparatus with large quantities of water, and 
hence forcing the heart to perform much labor in pumping the 
water from the stomach to the emunctories of the body. Conse- 
quently the total amount of milk should rarely exceed one quart 
in the extreme; and a little meat, fats, cereals, fresh fruits and 
vegetables should be added to the diet in order to make up the 
nutritive deficit. 



TREATMENT OF CARDIAC DROPSY AND EDEMA. 

Mild dropsical swellings about the ankles can usually be Re st and 
promptly relieved by rest in bed, massage and a milk diet. As 
soon, however, as an accumulation of serum occurs in the serous 
cavities and the subcutaneous tissues, more active treatment must 
be instituted. The means at our disposal are stimulation of the 
action of the sweat glands and the kidneys, and catharsis. If 
these measures fail, surgical treatment of hydrops must be in- 
stituted, either by incision or puncture of the edematous extremi- 
ties and drainage, or by paracentesis of the dropsical serous cav- 
ities. 

The stimulation of the sweat glands should be brought about Diaphoresis 
preferably by physical means; for we know of only one remedy Pilocarpine 
that really possesses the power of stimulating the sweat glands, ca t e d 
viz., jaborandi and its alkaloid, pilocarpine; and unfortunately 



*See Crofton: "Clinical Urinology." (Cleveland Press.) 



298 



DISEASES OF THE CIRCULATORY APPARATUS 



Hot air and 
steam sweats 



Precautions 



Heart tonics 
Diuresis 



Theobromin 
Diuretin 



this drug is distinctly contra-indicated in valvular diseases of the 
heart, for it depresses the heart decidedly ? slows its action and 
appreciably reduces arterial tension. 

Inasmuch as hot bathing is always dangerous in heart dis- 
eases, for reasons described herein (see index), recourse must 
be had to sweating by the use of hot air or steam. 
In order to do this at home the patient should be seated upon a 
chair, a woolen blanket fastened around his neck and draped in 
such a way about the person of the patient that it covers his whole 
body and the chair, i. e., forms a tent with the head protruding 
above. By placing a lamp underneath the chair a profuse sweat 
can soon be induced. Sweating in bed can be produced in the 
same way by arranging a frame work over the patient and cover- 
ing this with blankets. At the side of the bed is placed a lamp 
and over the lamp a metal funnel to which is attached a rubber 
tube which conducts hot air underneath the blanket, care being 
exercised, of course, that the patient is not burned by the hot air. 
If it is desired to give the patient a steam bath, the steam from 
a kettle of hot water may be conducted under the blanket tent 
by means of the same funnel and tube arrangement. 

In all of these procedures the patient's head should be kept 
cool with cold baths or an ice bag. The hot air or steam sweating 
may be kept up for ten or fifteen minutes with safety. At the 
end of the sweating the patient should be wrapped in blankets 
and allowed to remain quiet for half an hour; at the end of this 
time the surface of the body may to advantage be bathed in luke- 
warm water, dried with a rough towel and rubbed with alcohol. 

Among the diuretics that can be used for the relief of car- 
diac dropsy the heart tonics (digitalis and its congeners), and 
caffein, given either alone or combined, are the most useful rem- 
edies. To the caffein group belongs also the very popular medi- 
cine, theobromin, and its compound with sodium salicylate, diure- 
tin. All these caffein derivatives are renal diuretics and act by 
exciting the renal epithelia. Diuretin is best administered in pow- 
der form, in the dose of about ten to twenty grains (0.65 to 1.3 
gm.) three or four times a day. A useful prescription in cardiac 
dropsy consequently is : 



$ 



Powdered digitalis leaves 0.1 gm. 

Diuretin, 1.0 gm. 

Sugar of milk, 0.3 gm. 

M. Sig. One such powder three or four times 
a day. 



DISEASES OF THE CIRCULATORY APPARATUS 299 

As the hydrochloric acid of the stomach seems to interfere 
with the absorption of diuretin this drug can advantageously be 
given in combination with sodium bicarbonate in a little milk. 
If diuretin fails to increase the flow of urine after two or three 
days, its use had better be discontinued and recourse had to some 
other remedy, notably calomel, in doses of two grains (0.1 gm.) Calomel 
repeated five to ten times a day, for several days in succession. 
This treatment may be repeated at intervals of a week or ten 
days. The diuretic effect of this drug is very striking. It is con- 
tra-indicated, however, if nephritis exists, or if there is a severe 
anemia or much gastro-intestinal trouble. Salivation should be 
forestalled by the frequent use of a dilute solution of chlorate 
of potash or tannic acid as a mouth wash. (See Stomatitis.) If 
salivation appears, nevertheless, calomel should be stopped at once. 
To counteract the irritative diarrhea five grains (0.3 gm.) of pow- 
dered opium may be given daily. Diuretic teas were formerly Diuretic teas 
very popular, but they act presumably more through the hot 
water they contain than from any specific effect; as they must be 
taken in large quantities to be effective and as abundant water 
drinking is contra-indicated, their use cannot be recommended. 

Sugar of milk may also be utilized as a diuretic in these cases. Sugar of milk 
Inasmuch as these patients are, as a rule, living on a diet con- 
sisting largely of milk this effect is produced anyhow; the addi- 
tion of milk sugar in varying doses to the milk, however, fre- 
quently enforces the diuretic effect of the latter. Other sugars 
seem to possess a similar diuretic influence and the administra- 
tion of a solution of dextrose is occasionally very useful in in- 
creasing the flow of urine. 

Three classes of purgatives or hydragogue cathartics may be Catharsis 
used to advantage in 1 the treatment of renal dropsy, viz., saline 
cathartics, vegetable purgatives and mercurial purgatives. The 
chief saline cathartics are the sulphate of sodium (Glauber salt), Saline cathar- 
the sulphate of magnesium (Epsom salt), the double tartrate of 1CS 
sodium and potassium (Eochelle salt) and the citrate of potas- 
sium and magnesium. These salines, in contradistinction to the 
vegetable and mercurial purgatives, do not irritate the intestinal 
wall, but act chiefly by increasing the molecular concentration 
(i. e., the osmotic pressure) within the intestine, and hence draw 
water from the serum into the bowel. In this way the blood be- 
comes more concentrated and in its turn draws water from the 
tissues; the saline cathartics also stimulate the peristaltic move- 
ment of the bowel through their bulk and in this way hasten the 
propulsion onward of the bowel contents. 

Sodium sulphate may be given in doses of thirty grains to 
an ounce (2 to 30 gm.). The sulphate of magnesium in the 



300 



DISEASES OF THE CIRCULATORY APPARATUS 



Vegetable 
purgatives 



Croton oil 



Jalap 
Colocynth 
Podophyllum 
Elaterium 



Surgical 
treatment 



same quantities. Kochelle salts in doses of about one-fourth to 
one-half an ounce (8 to 16 gm.), and the citrate of potassium 
and magnesium in doses of fifteen to fifty grains (1 to 3 gm.). 
In addition there are a number of pleasant effervescent mixtures' 
that may be given. The concentration of the solutions of these 
different saline cathartics is very important. They should not 
be more concentrated than ten per cent. The disagreeable taste, 
especially of the magnesium salts, can often be disguised by the 
addition of a little sugar or by giving the salts in milk. 

Among the vegetable purgatives the oils, castor oil and croton 
oil, have a very subordinate importance in the treatment of car- 
diac dropsies, because they do not produce a sufficiently active 
purgation unless given in doses so large as to produce serious ir- 
ritation of the bowel wall. This applies particularly to croton 
oil. Inasmuch as the mucosa is generally in a state of passive 
hyperemia in cases of valvular heart lesions that have progressed 
to the stage of dropsy, it is particularly important not to give 
drugs that can irritate the bowel wall. The rhubarb, senna, aloes 
group are also little used in the treatment of cardiac dropsy; 
first, because they are all irritating and, second, because their 
action is relatively mild. The chief vegetable purgatives, there- 
fore, that we must use are jalap and colocynth, podophyllum and 
elaterium. Of all these jalap is the most deservedly popular. In- 
asmuch as this drug occasionally produces nausea ? vomiting and 
colic, it is best to combine it with hyoscine or belladonna, which 
counteract this effect. The following official preparations of the 
U. S. P. are all useful: The compound cathartic pill containing 
colocynth, jalap, gamboge and calomel, given three at a time. The 
vegetable cathartic pill containing colocynth, jalap, podophyllum, 
hyoscyamus and peppermint oil, given in similar doses as the 
above. The compond elaterin powder containing one part of 
elaterin in thirty-nine parts of milk sugar, and given in doses of 
one to four grains (0.06 to 0.25 )•, and finally, the pill of podophyl- 
lin, belladonna and capsicum. The appearance of blood or mucus 
in the stools, or other signs of gastric or intestinal irritation, con- 
tra-indicate the continuation of these remedies. 

If all these medicinal measures, with sweating by hot air or 
steam, fail to relieve the dropsy, then recourse must be had to 
what may be called the surgical treatment of cardiac hydrops. 

The surgical relief of hydrops or anasarca of* the lower ex- 
tremities is more than a palliative measure, for, in many cases 
it will be found that the withdrawal of the fluid from the serous 
cavities or limbs, when combined with active cardio-tonic medi- 
cation, enables the heart to regain its tone and occasionally aids 
in the re-establishment of compensation. Unfortunately this 



DISEASES OF THE CIRCULATORY APPARATUS 



301 



happy result is only rarely seen. The simplest and the safest 
way of removing the dropsical swelling of the extremities is to 
make an incision. The patient should be ordered to sit upright, 
or, at least, to keep the legs in a dependent position for several 
hours before the incision is made. The feet and legs are care- 
fully cleaned with soap and water and the skin rendered aseptic 
with bichloride solution, alcohol and ether. The best place for 
the incision is the external margin of the foot, below the external 
malleolus, or the dorsum of the foot. The incision should be 
at least an inch or two long and should be carried completely 
through the skin. By placing a cloth, wrung out of very hot 
water, over the wound immediately after the incision is made, 
bleeding can be stopped. The wound is then covered with a piece 
of bichloride gauze, the feet wrapped in cotton and placed in 
a pan containing a little dilute carbolic acid or bichloride so- 
lution. As soon as the bulk of the fluid is drained off the wound 
usually closes if a simple compression bandage is applied. 

A second method is the so-called Southey method, which con- 
sists in the insertion of a number of trocars deep into the sub- 
cutaneous tissues of the leg. That this little operation should 
be performed with all aseptic precautions need hardly be em- 
phasized. To the protruding ends of the little trocars are at- 
tached rubber tubes upon which suction may be advantageously 
exercised in the beginning in order to start the flow of the serum 
through the tube; the region around the trocar may be painted 
with iodoform collodion or may be covered with antiseptic gauze. 
After the fluid is drained off and the canulsee are withdrawn, the 
little holes can be closed with iodoform collodion or gauze. This 
method is not so safe as the incision method, nor does it produce 
the desired effect so rapidly. The method by incision, moreover, 
is not so painful as the insertion of trocars nor is the danger of 
infection of course so great from an open incised wound as from 
a semi-occluded punctured wound. 

The method finally of scarifying the tissues and cupping 
through a funnel that carries off the dropsical fluids and the blood 
is less practical and not as efficacious as incision or trocar drain- 
age. In draining off large quantities of anasarca fluid cerebral 
anemia occasionally develops, so that the patient becomes nau- 
seated and dizzy and finally faints. When this occurs drainage 
should at once be interrupted^ the patient's head lowered and 
ether or camphor administered hypodermically. 

Paracentesis for the removal of ascitic fluids is always indi- 
cated when the accumulated fluid mechanically presses the dia- 
phragm upward and in this way interferes with respiration and 



Incision 



Southey 
trocars 



Scarification 
and cupping 



Paracentesis 
of the ab- 
domen 



302 



DISEASES OF THE CIRCULATORY APPARATUS 



Technique 



Paracentesis 
of the pleural 
cavity and the 
pericardium 



the action of the heart, or if it compresses the stomach and bowels 
in such a way as to interfere with digestion. 

Occasionally paracentesis of the abdomen becomes necessary 
even without the appearance^ of compression symptoms in the 
thorax, without very considerable interference with the heart's 
action, and without the presence of much edema in other parts 
of the body. One is often surprised to find such an abdomen 
full of fluid in cases of valvular lesions that are not in an ad- 
vanced degree of decompensation. Here the development of the 
ascites is due to portal stasis superinduced by the existence of a 
"nutmeg" liver ("heart disease liver," cardiac cirrhosis) and 
compression of branches of the portal vein within the atrophied 
organ. 

When performing paracentesis of the abdomen cardiac stim- 
ulants should always be held in readiness in order to counteract 
the possible occurrence of cerebral anemia that may follow the 
sudden engorgement of the abdominal veins with blood when the 
fluid is withdrawn and the intra-abdominal pressure is relieved. 
The tapping can be made with an ordinary trocar and can be per- 
formed with the patient either in a recumbent or in a sitting 
position. The skin should be thoroughly cleansed with soap and 
water, bichloride solution, ether and alcohol, and when making 
the puncture care should be taken to avoid superficial blood ves- 
sels. If the abdominal wall is very edematous, the local anarsaca 
should first be removed by massage. It is usually a good plan to 
make a small incision before inserting the trocar, as the little 
operation is less painful if this is done. The entrance of the 
trocar into the addominal cavity is readily recognized by a cer- 
tain "give," and there is no danger of wounding the bowel in 
simple ascites. As soon as the bulk of the fluid has been tapped 
off, the bowel is usually felt to lightly touch the trocar point and 
the flow stops. This is the signal for withdrawing the needle. 
The wound is covered with a small piece of iodoform gauze and 
the latter attached to the skin with iodoform collodion. No other 
dressing is as a rule needed. The patient should be instructed 
to lie for half an hour or so on the side opposite the puncture. 
This treatment is, as a rule, merely palliative and has to be re- 
peated; the exceptions to this rule are the cases of hepatic ascites 
mentioned above, in which the withdrawal of ascitic fluid fre- 
quently exercises an effect that is very long lasting. 

Paracentesis of the pleural cavity is very rarely necessary in 
heart lesions. It is always an emergency measure and a last 
means to be resorted to only when the accumulation of fluid in 
the pleura is very great and respiration and the action of the heart 
are interfered with to such extent that death would occur unless 



DISEASES OE THE CIRCULATORY APPARATUS 



303 



the fluid were withdrawn. The technique of this proceedure will 
be found discussed under Phuritis. Paracentesis of the pericar- 
dium is probably never indicated in cardiac dropsy; the technique 
is discussed in the part on Pericarditis with effusion. 



MYOCARDITIS AND FATTY DEGENERATION OF 
THE HEART. 

Myocarditis is generally secondary to a variety of primary dis- 
orders of an infectious or toxic character. It is a common term- 
inal condition in diseases of the coronary arteries and failing 
compensation. Cachectic conditions, chronic anemias, acute ar- 
ticular rheumatism and malnutrition very often lead to myocar- 
dial changes; finally, it is a senile change. Causal and prophy- 
lactic treatment is throughout synonymous with the treatment of 
the underlying disorder. 

The recognition of myocarditis is never easy. The cardinal 
symptoms are a weak first sound at the apex, a weak second aortic 
sound, occasionally a fetal heart beat rhythm (embryo-cardia), 
low blood pressure, a slow, small, feeble, soft, compressible pulse. 
Moreover, a heart with myocarditis generally fails to react to 
digitalis, so that the diagnosis can occasionally be made if the 
heart does not become slower, the blood pressure higher and diure- 
sis increased after the administration of an appropriate dose of 
digitalis. 

The degeneration of the myocardium generally assumes a fatty 
type. In treating established myocarditis it is important to dis- 
tinguish between fatty infiltration of the heart muscle, due to 
degeneration of the muscle fibres, and fatty infiltration due to 
the interposition of fat between intact muscle bundles. The lat- 
ter condition is generally combined with fatty overgrowth about 
the heart and is in most cases a symptom of a general obesity. 
The symptoms of true degeneration of the heart muscle and of 
fatty heart (cor adiposum) are very similar, but the treatment 
is, as a rule, different. 

In the former instance the diet should be arranged in such 
a way as to reduce general obesity. The details are given in the 
Chapter on Disorders of Metabolism. OertePs Terrain cure is 
the most valuable means, however, for treating patients with cor 
adiposum. This exercise treatment stimulates oxidation, grad- 
ually exercises the heart muscle and hence helps restore its tone 
by favoring the back-flow from the periphery towards the heart, 
while at the same time stimulating the heart to increased con- 
tractions. This treatment, of course, can only be carried out in 
resorts that are arranged for such purpose. In myocarditis con- 



Causal and 

prophylactic 

treatment 



Recognition 



Types 



Fatty infiltra- 
tion and fatty 
degeneration 



Diet in fat 
heart 



304 



DISEASES OF THE CIRCULATORY APPARATUS 



Acute myocar- 
ditis 



Myocarditis in 
acute articular 
rheumatism 



Chronic myo- 
carditis 



secutive to coronary or valvular disease with failing compensa- 
tion it should, however, never be employed. 

In early stages of myocarditis the same principles should 
obtain as in the treatment of valvular disease of the heart with 
failing compensation, and of endocarditis. (For the details of 
this treatment I refer to the respective sections.) 

Acute myocarditis, when fully developed, should be treated 
by rest, physical and mental, a bland, non-irritating diet and 
counter-irritation over the precordium by means of cold, leeches, 
cupping or plasters. Digitalis and other cardiac tonics should 
always be used with great care in acute myocarditis, especially if 
the digitalis does not become apparent within two or three days 
after the commencement of its administration. In emergencies 
analeptics may have to be given to save life (camphor, ether, am- 
monia). 

In myocarditis developing in the course of acute articular 
rheumatism, salicylate of soda should be discontinued at once 
and quinine and alkalies administered instead, the former as 
quinine sulphate in doses of three to five grains (0.2 to 0.3 
gm.) ; the latter preferably as sodium bicarbonate, in doses of 
fifteen to thirty grains (1 to 2 gm.). 

In chronic myocarditis due to fibroid degeneration and atrophy 
of the heart muscle, restitution to normal conditions is impossible 
and treatment is altogether palliative. All violent exercise, men- 
tal over-strain or worry, and emotional shocks should be carefully 
avoided. Sexual intercourse should be absolutely forbidden. The 
general health should be built up by a nutritious diet appropriate 
to the state of the digestive organs. Tea, coffee, alcohol and to- 
bacco should be interdicted. A course of arsenic often acts as an 
effective general tonic. Fowler's solution should be given, be- 
ginning with two or three drops a day and gradually increasing 
the dose until twenty or thirty drops a day are taken, and then 
slowly reducing the dose until two or three drops are again 
reached ; such a course may be repeated two or three times. Con- 
stipation and flatulency should be counteracted and anemia treated 
by appropriate remedies (see index). Cardiac tonics should be 
given, if at all, under careful- supervision, and the same general 
rules should be followed as in the treatment of valvular diseases 
during the stage of compensation. 



ACUTE ENDOCARDITIS. 



Acute endocarditis may appear as a primary affection, but 
it usually complicates a great variety of general diseases, chief 
among them acute articular rheumatism, scarlet fever, pneu- 



DISEASES OF THE CIRCULATORY APPARATUS 305 

monia, chorea, septicemia, erysipelas and gonorrhea. Syphilis 
and all cachectic states also occasionally determine inflammation 
of the endocardium. 

Prophylactic treatment is identical with the treatment of the Prophylaxis 
underlying disorders. Absolute rest in bed, and cold to the pre- 
cordium, are the only measures that can be adopted to reduce 
the liability of the endocardium to involvement in the disease 
process. Eest, above all, should be enforced in acute articular 
rheumatism, gonorrheal arthritis and chorea, even if the general 
manifestations are slight, for, in the mildest case the liability of 
the endocardium to involvement should be remembered and, abso- 
lute rest insisted upon. In many cases of tonsillitis, too^ the 
heart should be repeatedly examined and upon the appearance of 
the slightest signs of endocarditis the patient at once put to bed. 

In septic, sell., ulcerative endocarditis occurring in the course Septic form 
of septicemia and puerperal pyemia, orthocresol, quinine and mer- 
cury bichloride have been recommended. Very little at best can, 
however, be expected from any medicine in this disease. In view 
of the serious and usually hopeless character of this malignant 
form of endocarditis these remedies should, however, be tried, 
for it is always better at least to try a medicine that can do no 
barm than to stand by without doing anything and lazily con- 
template the death of the patient. The use of carbolic acid sub- 
cutaneously and intravenously will be found discussed at length 
in the Chapter on Malaria. Quinine and mercury bichloride may 
be given combined, the former as the sulphate or the hydrochlorate, 
in doses of from five to fifteen grains (0.3 to 1 gm.) ; the latter in 
the dose of from one-thirty-second to one-sixth grain (0.002 to 
0.01 gm.) in pill or capsule, preferably with milk. 

In the syphilitic form of endocarditis the ordinary antiluetic Syphilitic 
medication (see Section on Syphilis) must be used. In the rheu- m 
matic form salicylates combined with alkalies, preferably the lat- 
ter in view of the possibility of myocardial complications in which 
salicylates do harm. Salicylic medication, moreover, seems to 
exercise a less profound effect in rheumatic disorders upon the 
endocardium (and pericardium) than upon the serous membranes Rheumatic 
lining the joints. For the mode of administering salicylates, al- rm 
kalies and quinine in rheumatic endocarditis, I refer to the Sec- 
tion on Acute Articular Rheumatism. 

With endocarditic inflammation once fully established the Pest 
treatment varies according to the stage of the disease. Through- Counter-irrita- 
out the course of the endocarditis absolute rest in bed should 
be enforced; cold should be applied to the precordium, either by 
means of a Leiter coil or an ice bag,, either continuously or with 
interruptions, the latter plan being generally preferable and less 



306 



DISEASES OF THE CIRCULATORY APPARATUS 



Medicamen- 
tous treat- 
ment 



Aconite 



Digitalis 



Absorption of 
the exudate 



Diet 



disagreeable to the patient. Early in the affection cupping, leech- 
ing or counter-irritation with iodine, blisters or plasters over the 
heart can do no harm. 

The medicamentous treatment in the beginning must be chiefly 
directed towards maintaining the tone of the heart and preventing 
cardiac insufficiency. Here the tincture of aconite, one to five 
drops given every few hours, is the best remedy, especially in 
sthenic cases when the heart beats fast and strong; for this drug 
quiets the heart, slows its action and reduces the blood pressure; 
in other words, relieves the heart of much strain and reduces 
its labor. Later, when the heart is beginning to fail and its action 
is accelerated but weak and irregular, and stasis or hydrops in 
different organs begin to appear^ then digitalis should be used. 
In early stages of the disease, therefore, aconite is the proper 
remedy; in later stages digitalis. It is clear that occasionally 
these drugs may have to be given together. 

No drug that we know of can produce absorption of the vege- 
tations on the valves of the heart after they have once formed. 
Chloride of ammonia, sodium carbonate and the iodides of soda 
and potash have all been recommended for this purpose; but the 
claims for these remedies have never been substantiated clinically, 
so that these drugs had better not be given in endocarditis, es- 
pecially as their administration may do more harm than good 
by irritating the stomach and interfering with digestion. Iodides 
have a place in chronic endocarditis, not on account of their ef- 
fect upon the vegetations, but for their effect on the blood pres- 
sure. 

The diet in acute endocarditis should consist largely of milk, 
gruels and broths, with the additions of a little toast, a few crack- 
ers, a little fresh fruit and vegetables. 

During convalescence, in view of the valvular heart lesions 
that usually remain, the treatment becomes the same as in com- 
pensated or decompensated valvular lesions of the heart and I 
refer to those chapters for the details. 



PERICARDITIS. 



Cold 

Quinine 

Morphine 



The treatment of pericarditis varies according to the stage 
of the disease and the character of the effusion or exudate in the 
pericardium. Upon the appearance of the first symptoms of 
pericarditis absolute rest in bed, with an ice bag or a Leiter coal 
over the heart, should be enforced; five to fifteen grains (0.3 to 
1 gm.) of quinine should be administered in divided doses; and 
if the pain is very severe a fourth of a grain of morphine hypo- 



DISEASES OF THE CIRCULATORY APPARATUS 



307 



Warm Priess- 
nitz com- 
press 



Plasters and 
poultices 



Diet 



Rheumatic 
form 



dermically, two or three times a day for two or three days. If 
the case cannot bear cold to the precordium, a warm Priesnitz 
compress should be applied, consisting of a linen cloth wrung 
ont of hot water and covered with several layers of flannel. This 
should be left on undisturbed for several hours and then renewed. 
Oatmeal or bread poultices, belladonna or veratrine plasters or 
ointments also often relieve the pain. Cold or heat or counter- 
irritants applied in this way to the precordium produce dila- 
tation of the cutaneous blood vessels of this area and hence re- 
lieve the congestion in the underlying pericardial sac; they also 
reflexly deplete the pericardium. These measures usually promptly 
relieve at least the disagreeable subjective sensations of the patient. 

The diet in the early stage should be non-irritating and should 
consist of liquids, milk, gruels, possibly with the addition of 
a little toast, bread and butter or some stewed fruit or vegetables. 

No medicines can act directly curatively. In the tuberculous 
variety ideal hygienic conditions and a proper diet, as described 
in the Chapter on Tuberculosis should be insisted upon. 

In the rheumatic forms of pericarditis an alkaline salicylate 
treatment may occasionally aid in preventing pericarditis, but 
upon the establishment of pericardial inflammation the use of 
salicylates should be discontinued and quinine and alkalies given 
instead. 

In early stages if the patient is not weakened by disease, and 
if the heart's action is rapid and tumultuous, aconite is the best 
remedy, preferably given in 1 doses of from one to five drops of 
a good tincture, every two or three hours. Digitalis should be Digitalis 
given with care, especially in pericarditis with large amounts of 
effusion, because digitalis prolongs the diastolic dilatation of the 
auricles and this particular action of the heart is always rendered 
difiicult when pressure is exercised upon it from without, as, for 
instance, by a large pericardial exudate. If digitalis is admin- 
istered at all the pulse should be carefully watched. In very ad- 
vanced degrees of pericarditis, in which the heart's action be- 
comes seriously impaired from excessive labor imposed upon the 
organ, digitalis and occasionally analeptics must be employed 
as an emergency measure in order to save life. If it becomes very 
slow, 65 beats to the minute or below, or markedly di- 
crotic, digitalis should be discontinued at once. Digitalis, how- 
ever, has a place in the treatment of early stages of pericarditis 
without much effusion, for here it is very important that the 
heart's action should remain as energetic as possible, because in 
this way the formation of fibrinous adhesions may be rendered 
difiicult and possibly prevented. 



308 



DISEASES OF THE CIRCULATORY APPARATUS 



Diuresis and 
catharsis 



Paracentesis 
of the peri- 
cardium and 
pericardiotomy 



The treatment of large pericardial exudates that form after 
the acute stage of the disease is over, or of pericarditis that sets in 
with a large serous exudate, must be considered separately. Here 
an energetic diuretic treatment, as discussed under the heading 
of cardiac dropsies,, combined with catharsis, may be employed 
with the object of ridding the organism of much water through 
the kidneys and bowel, thus concentrating the blood and conse- 
quently promoting the reabsorption of the pericardial exudate. 
Only occasionally, however, can pericardial fluid be made to dis- 
appear in this way. 

In case medical measures fail, then surgical treatment must 
be instituted, consisting either in paracentesis of the pericardium 
or pericardiotomy. The latter measure should always be adopted 
if the fluid contained within the pericardial sac is purulent. Here 
the pericardium should be broadly incised and free drainage es- 
tablished. This procedure must be carried out by a surgeon and 
the details need not be discussed in this book. 

Puncture of the pericardium, however, is a task that every 
internist should be able to perform. The skin is carefully shaved 
and rendered aseptic by scrubbing with soap and water, one to 
two thousand bichloride solution, alcohol and ether. The trocar 
should be inserted either in the fifth or the fourth intercostal 
space on the left side about an inch from the left sternal margin. 
This point is selected in order to avoid wounding the mammillary 
vessels. It is usually best to use a local anesthetic, for instance 
an ether or chloride of ethyl spray, and to make a small incision 
at the point where the trocar is to be inserted. The nature of 
the operation should always be explained to the patient in order 
that he may remain quiet, exercise self-control and co-operate 
with the physician. The patient will usually have to be operated 
upon in a semi-recumbent position; if it is at all possible, how- 
ever, he should be laid flat on his back. In order to avoid in- 
juring the heart the needle should be introduced at first directly 
backwards and then backwards and, downwards very slowly and 
carefully and not, as in paracentesis abdominis, quickly. The 
fluid should be withdrawn gradually and a hypodermic injec- 
tion of ether or camphorated oil be given while the fluid is being 
removed. The operation is not without danger and should only 
be resorted to as an emergency measure when all other means 
have failed; for cases are on record in which the heart was in- 
jured and death occurred during the operation. Puncture of the 
pericardium from the xiphoid angle on the left side by inserting 
the trocar upwards and backwards is still more dangerous and 
can only be carried out with relative safety in enormous pericardial 
exudates. 



DISEASES OF THE CIRCULATORY APPARATUS 



309 



THE ARTERIES. 



ARTERIO-SCLEROSIS AND CHRONIC AORTITIS. 

Arteriosclerosis in the majority of cases is the result of 
premature or normal senility. Causal treatment, therefore, in 
this category is self-evidently impossible. A small minority of 
the cases of arterio-sclerosis and chronic aortitis are due to meta- 
bolic disorders, viz., gout, diabetes and obesity, or to certain chronic 
intoxications and chronic intestinal derangements, to the abuse of 
alcohol, tobacco and lead, and, above all, to syphilis. The causal 
treatment of all these forms of arterial degeneration is synonymous 
with the treatment of the underlying conditions, and will be dis- 
cussed in their appropriate parts. 

Symptomatic treatment must be directed chiefly towards pre- 
venting the over-tension of the peripheral vessels; in other words, 
towards keeping down the blood pressure. For the diseased ar- 
terial walls, owing to their lack of elasticity, determine high pres- 
sure and the high pressure in its turn presumably produces further 
degeneration of the arterial muscularis. It is hard to say in many 
of the cases which was the primary event, the high tension of the 
blood or the arterial degeneration, i. e., the sclerosis. The dietetic 
rules to be observed are the following: Alcoholic beverages and 
tobacco, as well as tea and coffee, should either be forbidden al- 
together or should be allowed only very moderately. Meat should 
be reduced to a minimum, and particularly those varieties of meat 
and meat preparations excluded from the diet that are known to 
contain extractives, for the latter raise the blood pressure (see 
index). A diet consisting largely of milk and plenty of fresh 
fruits and vegetables, cereals and a moderate amount of fats is 
the best. In so chronic a disorder as arterio-sclerosis care must, 
above all things, however, be taken to maintain general nutrition. 

As one of the characteristics of arterio-sclerosis is calcification 
of the arteries, it has been suggested that the ingestion of cal- 
cium should be reduced by excluding from the diet articles of 
food containing this element; chief among them eggs, cheese, 
rice, asparagus, carrots and milk. It will be seen that, on the 
basis of this theoretical postulate, a milk diet would be danger- 
ous and a meat diet permissible. Practical experience teaches, 
however, that patients with arterio-sclerosis thrive very much bet- 
ter on a diet consisting largely of milk and the other articles enu- 
merated above than on a meat diet, hence the decalcification plan, 
however seductive it may appear on theoretical grounds, is not 
practical. The suggestion has been made to counteract the de- 
posit of calcium salts by the administration of lactic acid by 
mouth, and it can do no harm to adopt this plan, especially as 



Causal treat- 
ment 



Symptomatic 
treatment 



Diet 



Reduction of 
calcium salts 



Lactic acid 
therapy 



310 



DISEASES OF THE CIRCULATORY APPARATUS 



Restriction of 
liquids 

Bathing 

Climate and 
altitude 



Iodides of 
potash and 
soda 



Dose and ad- 
ministration 



Alkalies 



lactic acid acts as an intestinal antiseptic and may be useful from 
this point of view. Lactic acid may be administered in the form 
of sodium or strontium lactate, in the dose of fifteen to twenty 
grains (0.1 to 1.2 gm.) three times a day, or as lactic acid in solu- 
tion in syrup (1:20) a teaspoonful three or four times a day. 

The ingestion of liquids should be somewhat restricted, for 
similar principles obtain here as in the treatment of compen- 
sated heart lesions. The same applies to bathing and other hy- 
drotherapeutic means, and the choice of a resort, climate and 
altitude. For the considerations that should govern us in advising 
our patients in regard to these elements of the treatment I there- 
fore refer to Compensated Heart Lesions. 

The medicamentous treatment of arterio-sclerosis consists, 
first, in the use of the iodides, either of potash or sodium. Iodides 
have long enjoyed a great popularity in the treatment of this 
disorder, and there is no doubt that empirically they act benefi- 
cially in arterio-sclerosis. It seems very doubtful whether iodides 
can, in any way, cause regeneration of the sclerotic arterial walls, 
as some writers claim. They certainly, however, keep the blood 
pressure low and this, as I have explained above, may aid Nature 
in partially restoring normal conditions. Iodides, according to 
the investigations of Bomberg, presumably produce this effect by 
reducing the viscosity of the blood, in other words, rendering it 
more fluid without diluting it. This is a very useful influence, for 
in arterio-sclerosis, owing to the rigidity of the arteries and the 
narrowing of their lumen, the propulsion of the blood is always 
impeded; if now the blood viscosity can be reduced it will flow 
more readily through the arteries and this factor, by relieving 
the heart of much labor, reduces the blood pressure. The iodides, 
moreover, exercise a very striking effect upon the subjective symp- 
toms of the patient, especially the neurasthenic manifestations, 
the angina, the dyspnea, and the cardiac asthma. In order to be 
effective they should be given for long periods of time, preferably 
for years. In the beginning small doses, i. e., two to ten grains 
(0.12 to 0.6 gm.) should be given three times a day and the dose 
later increased a little. In order to enforce the effect of the iodides 
they should be administered in combination with some alkali, pref- 
erably the bicarbonate of soda, or dissolved in some alkaline water. 
A very useful method of administering them is to give two to 
ten drops of the saturated solution of iodide of sodium in a glass 
of milk, to which is added one-third of a teaspoonful of bicar- 
bonate of sodium. Iodides are best given after a meal ; they should 
never be administered together with acid foods, nor to patients 
suffering from gastric catarrh, and should never be administered 
in a metal spoon. In order to prevent the development of iodism 



DISEASES OF THE CIRCULATORY APPARATUS 311 

the administration of the iodides should be interrupted from time 
to time, and a very good plan is to give them for three weeks con- 
secutive, then to stop their use for one week and later possibly to 
omit them for two or three weeks at a time. 

A very valuable remedy for internal use is also iodipin. This Iodipin 
is a solution of iodin in sesame oil, administered in ten per cent. 
strength in capsules, daily, 0.5 g. The same remedy can be used 
hypodermically in doses of 15 to 30 minims. 

For the purpose of reducing the blood pressure, the nitrates Nitrites 
may also be used; they are best administered in the form of ni- 
trates combined with sodium bicarbonate, as the nitrates undergo 
reduction to nitrites in the body. Lauder Brunton, who first ad- 
vocated this treatment^ recommended the following formula: 

Potassium bicarbonate, 1.8 

Potassium nitrate, 1.2 

Sodium nitrate, 0.03 

To be given in half a litre of water, early in 
the morning, on an empty stomach. 

Or nitrite of soda may be given in tablets or solution in the 
dose of one to two grains (0.05 to 0.1 gm.). 

Nitroglycerin and amyl nitrite are of very subordinate im- Nitroglycerin 
portance in the treatment of arterio-sclerosis. They are chiefly nitrite^ 
useful to relieve paroxysms of angina pectoris, or to stop the 
retro-sternal pain that is so distressing a symptom in chronic aor- 
titis. This pain is also materially relieved by the application of 
the ice bag, poultices and counter irritants to the precordial region. 

One of the most valuable adjuvants in the prophylaxis and the Venesection 
treatment of arterio-sclerosis is periodic venesection with the with- 
drawal of small quantities of blood. There is no better means 
of reducing the blood pressure and the peripheral resistance than 
this. At the same time a certain amount of toxic material is 
removed and especially of C0 2 . The less C0 2 the blood con- 
tains the more the blood vessels are apt to become dilated and the 
blood pressure to fall. The viscosity of the blood also becomes 
reduced. One need not fear to produce anemia by repeated bleed- 
ing. On the contrary the occasional withdrawal of a little blood 
constitutes a powerful stimulus to the regeneration of the blood. 

Theocin, incidentally one of the most valuable diuretics, espe- Theocin 
cially when a salt-free diet is at the same time ordered (see De- 
chloridisation) is particularly useful in arterio-sclerosis and myo- 
carditis, as it seems to exercise a regulatory action upon the heart, 
causing cardiac dilatation to become reduced and the systolic con- 



312 



DISEASES OF THE CIRCULATORY APPARATUS 



Heart tonics 



Truneczek's 
serum 

Anti-sclerosin 



tractions of the heart to become more vigorous. In angina pec- 
toris it occasionally aids in controlling the attacks. 

Heart tonics should be given with care in arterio-schlerosis, 
on account of the inability of the arteries to adapt themselves 
rapidly to blood pressure changes. In later stages of the dis- 
ease, however, when the heart has become insufficient and the blood 
pressure is low, digitalis, administered continuously in small doses, 
has its place. Groedel, than whom there is probably no greater 
authority on this subject^ speaks very warmly of this practice and 
claims never to have seen any deleterious effect from it. 

Of late years Truneczek has described a serum to be used in 
arterio-sclerosis, and Goldschmidt a preparation called anti-sclero- 
sin. Some good results are reported from the use of these reme- 
dies, but it is too early to pass judgment on their efficacy. 

In suspected syphilitic arterio-sclerosis antiluetic medication 
is, of course, indicated. 



ANEURISM OF THE AORTA. 



Causal treat- 
ment 



Rest 



Diet 



Aneurism of the aorta occasionally undergoes spontaneous cure 
by the deposit of coagulates of fibrin within the aneurismal sac. 
All causal treatment that we can employ for the cure of aneurism 
must, therefore, be directed towards aiding Nature in producing 
such coagulates. In order to fulfill this purpose an endeavor must 
be made to cause retardation of the blood stream and a reduction 
of the blood pressure, and if possible, a decrease of the blood vol- 
ume, for all these factors favor coagulation. 

Absolute rest in bed for many months at a time is the ortho- 
dox treatment of this disease. When this plan is adopted, the 
contractions of the heart are reduced by many thousands in the 
twenty-four hours. Thus Baumler, for instance, showed in a case 
of aneurism that the pulse fell from 95 to 56 after forty minutes 
of absolute rest. This means the elimination of 43,200 contrac- 
tions of the heart in twenty-four hours. 

The amount of food and drink should always be reduced in 
order to decrease both the blood volume and the blood pressure. 
It is never ? however, a good plan to chronically underfeed these 
cases, for a starving organism cannot develop full regenerative 
powers. As the patients are resting and quiescent the daily food 
requirement is eo ipso less; but in order to be perfectly safe it 
is always best to submit these cases, after they have been in bed 
for a number of days and their metabolism has adjusted itself 
to the new conditions, to a careful metabolic study, in order to 
determine what the minimum amount of food is that the patients 



DISEASES OF THE CIRCULATORY APPARATUS 



313 



require to maintain nutritive equilibrium. The technique of such 
an examination will be found described in the Chapter on Diseases 
of Metabolism. 

The selection of the diet should be governed by the same prin- 
ciples that obtain in myocarditis and arterio-sclerosis. Large 
meals that can overload the stomach, or articles of diet that un- 
dergo fermentation and hence can distend the stomach, thus press- 
ing the diaphragm upwards and interfering with respiration and 
the work of the right heart, should always be avoided. If full 
feeding is permitted, therefore, the patient should receive small 
meals at frequent intervals. 

One of the most popular dietetic schemes employed in the 
treatment of aortic aneurism is the regime arranged by Tufnell. 
His diet is altogether inadequate to properly nourish the patients; 
and while he obtained remarkable success in some cases, it is 
nevertheless, a precarious matter to adopt so low a diet scheme 
as a routine. Tufnell advised restricting the total amount of 
solid food to 300 grammes in the twenty-four hours and the liquids 
to 240 cubic centimeters. This ration he allowed to be slightly 
increased if the patient became excited and very much dissatisfied 
with the restricted regime. The meals were arranged as follows: 
For breakfast: 50 cc. of milk or cocoa with 60 grammes of 
bread and butter. 

For dinner: 90 grammes of meat and 90 grammes of bread or 
potatoes and 120 cc. of water or very thin claret. 

For supper: 60 cc. of weak tea and 60 grammes of bread and 
butter. 

It is unnecessary to carry the restrictions so far, as equally 
good results are obtained with more liberal feeding, especially 
if a metabolic study precedes the arrangement of the dietary. 
TufnelFs scheme is, therefore, mentioned chiefly on account of 
its historical interest and because he deserves the credit of hav- 
ing first established the principle of restricted feeding in the treat- 
ment of aortic aneurism. 

It should rarely be necessary to reduce the liquids to less than 
1,000 cc. in twenty-four hours. When the liquids are greatly re- 
duced the patients naturally suffer from thirst; this distressing 
symptom can frequently be relieved without undue increase of 
the liquid intake by swallowing small pieces of cracked ice ad 
libitum, or by chewing gum. 

Care should always be taken to promote free evacuation of the 
bowels, because straining at stool is always a precarious matter 
in aneurism of the aorta, and the abdominal plethora is to be 
avoided besides. The lower extremities of the patient should be 
kept warm and the legs and abdomen frequently massaged; these 



Tufnell diet 



More liberal 
feeding 



Restriction of 
Liquids 



Free evacua- 
tion of the 
bowels 

Massage of 
the lower ex- 
tremities 



314 



DISEASES OF THE CIRCULATORY APPARATUS 



Medicamen- 
tous treat- 
ment 

Iodides 



Gelatine 



measures act beneficially, because both the heat and the massage 
reduce the peripheral blood pressure and draw much blood away 
temporarily from the region of the aneurism. 

The medical treatment of aneurism of the aorta is of very sub- 
ordinate importance. The iodides of potassium and sodium are 
used extensively. It is very doubtful, however, whether they ex- 
ercise any influence whatsoever upon the progress or regress of 
the aneurism itself. Symptomatically, they often stop the pain 
in the precordium and the left upper extremity. They should be 
given in increasing doses, preferably beginning with five drops 
of the saturated solution three times a day and gradually increas- 
ing the dose until thirty or forty grains are being taken daily 
or the desired effect is produced. The same principle and tech- 
nique should govern the administration of iodides in aneurism of 
the aorta as in arterio-sclerosis. (See index.) 

The subcutaneous injection of gelatine has recently been rec- 
ommended in the treatment of aneurism, and the claim has been 
made that gelatine administered in this way increases the coagula- 
bility of the blood, and hence favors the deposit of fibrin within 
the aneurismal sac. As gelatin is made from the hoofs of animals, 
there is always some danger of its containing spores of tetanus, 
and hence the gelatine solution should be very carefully sterilized 
before it is administered, as very disagreeable accidents have hap- 
pened when this precaution was omitted. One of the best solu- 
tions to use for sub-cutaneous injection is the following: 

Gelatine, 1.5 gm. 

Sodium chloride, 0.1 gm. 

Distilled water, 100.0 cc. 

M. Sig. : To be sterilized by discontinued sterilization and 
injected warm in doses of 20 to 30 ec. on four or five 
successive days. 

The injections are best made in the gluteal region. They are 
frequently followed within a day or two by severe pain in the 
region of the puncture and occasionally by a rise of temperature. 
The pain may be relieved by local heat; the fever rarely lasts 
more than forty-eight hours and can be safely neglected. 

The results obtained from this practice have been sufficiently 
favorable in some cases, especially when combined with certain 
other local measures to be discussed below, to warrant its em- 
ployment, tentatively, at least, in sacculated aneurism. In the 
fusiform variety, or in dissecting aneurism, no good results have 
ever been published. One of the chief indices of the efficacy of 
gelatine injections is considered to be the disappearance of the rad- 



DISEASES OP THE CIRCULATORY APPARATUS 



315 



Surgical 
treatment 



Galvano- 
puncture 



iating pains in the left upper extremity ? signifying that the nerves 
of the brachial plexus have been relieved of some pressure on the 
part of the aneurism. A series of X-ray photographs may indicate 
ad oculos whether or not the size of the aneurism has been reduced. 

In addition to these hygienic, dietetic and medicinal measures, 
certain surgical means may be employed to advantage in the treat- 
ment of aneurism, viz., in the order of their importance, galvano- 
puncture, acupuncture, flilipuncture, proximal compression (ap- 
plicable only to aneurism of the abdominal aorta) and ligation of 
the carotid and subclavian. 

Oalvano puncture is performed as follows : A fine insulated 
needle is introduced into the aneurismal sac and connected with 
the anode of a galvanic battery. The cathode is attached to a sponge 
electrode that may be applied to the chest or the abdomen. Some 
authorities recommend inserting two needles into the aneurismal 
sac, the one connected with the anode, the other with the cathode. 
The former plan, however, is simpler and safer and produces the 
same results as the latter. The current should not be stronger 
than from ten to twenty milliamperes, and it should not be ap- 
plied for longer than from fifteen to twenty minutes. It is well 
to test the coagulating power of the current before the needles 
are introduced into the aneurism, and this can be done as fol- 
lows: The white of an egg is poured into a dish and the needles 
inserted into it. When the current is turned on a firm clot should 
form at the positive needle while a frothy clot forms at the nega- 
tive pole. 

Before the needles are introduced into the aneurism the pa- 
tient should be told what it is intended to do, so that he may in- 
telligently co-operate with the physican and exercise all his will 
power in remaining absolutely still. When the treatment is over, 
the needles are rapidly withdrawn and the little wound closed 
with collodion or court plaster. As a rule it is necessary to re- 
peat this treatment two or three times at intervals of a week or 
so. There is always some danger of hemorrhage, and the possi- 
bility of embolism can never be excluded. A cure from this treat- 
ment is exceedingly rare, but quite a number of cases of aneuris- 
mal swellings have been reduced in size and the pain ameliorated. 

Filipuncture consists in introducing fine needles into the an- Filipuncture 
eurismal sac, as above,, and scarifying the intima of the opposite 
wall. The roughening of the intima is intended to favor the de- 
posit of fibrin and coagulates. A few cases of symptomatic im- 
provement but no cures are reported from this treatment. 

Acupuncture consists in the introduction of iron or silver wire, 
horse-hair, silk thread or cat-gut into the aneurism, the object be- 



Acupunture 



316 



DISEASES OF THE CIRCULATORY APPARATUS 



ing to cause the precipitation of fibrin around these threads. As 
a rule, the pieces are only a few millimeters long; threads and 
wires several centimeters long have been introduced, however, with- 
out untoward results, but, unfortunately, also without particularly 
favorable effects. As this operation is very simple and seems to 
be practically devoid of danger, and as it occasionally does some 
good, it may be employed, but only in desperate cases, in which 
all other means have failed. 
Compression I n aneurism of the abdominal aorta situated low down, com- 

pression of the aorta between the heart and the aneurism has been 
attempted; the object being to cause retardation and stasis of 
the blood stream in the aneurismal sac and thereby creating con- 
ditions that favor coagulation and hence obliteration of the aneur- 
ismal cavity. This procedure must, of course, be carried out under 
an anesthetic. The duration of the operation must vary accord- 
ing to the reaction of the patient, but in order to exercise any 
effect compression should be continued for several hours. The 
amount of pressure should be so great as to cause disappearance 
of pulsation in the sac. The operation may be repeated. The 
results reported are not particularly favorable and untoward con- 
sequences have occasionally been observed, for instance, peritonitis 
and mechanical lesions of the duodenum^ the pancreas and the 
celiac plexus from the pressure. 

Ligation of the common carotid and the sub-clavian artery has 
been used as a desperate resort, but no good results are reported 
from this operation. It is mentioned merely for completeness' 
sake and on account of its historical interest. 

That these various surgical measures must be combined with 
rest and a restricted diet, possibly the use of iodides and gelatine, 
(see above), need hardly be emphasized. 

The symptomatic treatment of aortic aneurism concerns itself 
chiefly with the relief of pressure symptoms. Chief among these 
are pain radiating in various directions according to the location 
of the aneurism and the nerve branches compressed; venous con- 
gestion in various organs of the body, chiefly the head and arms 
in aneurisms of the upper aorta ; dyspnea from compression of the 
trachea or from congestive bronchitis or from bilateral abductor 
paralysis (pressure on the recurrent laryngeal nerve at the aortic 
arch) . 
Relief of pain For the relief of the pain the ordinary anti-neuralgic remedies 

may be employed. For the pain produced by the aneurism itself 
the ice bag or a Leiter coil to the precordium may be used ts de- 
scribed in the part on Pericarditis. Occasionally a narcotic or 
anodyne ointment applied to the chest relieves the pain. A very 



Ligation of 
carotid and 
subclavian 
arteries 



Symptomatic 
treatment 



DISEASES OF THE CIRCULATORY APPARATUS 



317 



useful prescription for such an ointment, recommended by Ortner, 
is the following: 

Menthol, 2.0 gm. 

Cocaine muriate, 0.2 gm. 

Morphine muriate, 0.4 gm. 

Olive oil, 1.0 cc. 

Lanolin, 2.0 gm. 
M. Sig: Apply locally. 

For the dyspnea due to pressure hyperemia of the trachea or Dyspnea 
bronchial mucosa, the ordinary remedies for bronchitis should 
be employed (see Section on Bronchitis). The same precaution in 
the selection of expectorants should be observed, however, as in 
the treatment of the bronchitis due to venous stasis in decom- 
pensated heart lesions, and particular care should be exercised to 
avoid the administration of emetic expectorants, chiefly ipecac, 
because the strain of vomiting is always dangerous in aneurism. 

Bleeding is a very useful measure in aneurism because it rap- 
idly relieves the congestion and generally stops the pain. This 
applies particularly to the disagreeable congestion occurring about 
the face, head, neck and upper extremity; here bleeding is with- 
out doubt the sovereign remedy for producing symptomatic re- 
lief. Repeated blood-letting with the withdrawal of small quan- 
tities of blood is the best method of venesection. 

Disagreeable symptoms resulting from the pressure of the 
aneurism on the vagus or the phrenic nerve must often be re- 
lieved symptomatically by the use of opium or bromides and oc- 
casionally, in emergencies, by whiffs of chloroform. Sometimes 
it may become necessary to perform tracheotomy in order to re- 
lieve laryngeal dyspnea due to bilateral abductor paralysis, result- 
ing from pressure of the aneurism upon the laryngeal nerves. 



Venesection 



Pressure 
symptoms 



NEUROSES OF THE HEART. 



ANGINA PECTORIS. 

Angina pectoris is, in most cases, due to ischemia of the heart 
muscle. The factors that determine an inadequate supply of blood 
to the heart are manifold, and may be either organic or functional 
in character. In most instances angina pectoris is a symptom of 
a general arterio-sclerosis involving the coronary arteries and, 
possibly, also the endocardium; in other cases it appears that the 
coronary arteries alone are sclerotic, and, in still other cases, there 
is an aortitis, due to different causes, producing mechanical nar- 



318 



DISEASES OF THE CIRCULATORY APPARATUS 



Causal treat- 
ment 



Prophylaxis 



Diet 



Vaso-dilators 
in high pres- 
sure angina 



rowing of the orifices of the coronary arteries in the aortic wall; 
or there may be thrombosis or embolism of these vessels. Besides, 
spasmodic contraction of the walls of the coronary arteries, due 
to a variety of possible neurotic causes, may occur. Finally, there 
is also a symptomatic form, so-called pseudo-angina, that occasion- 
ally develops on the basis of a neurasthenic or hysterical condition. 

The causal treatment of angina pectoris must, therefore, take 
all these different possibilities into consideration. Thus all the 
factors that can become operative to produce arterio-sclerosis or 
arteritis should be treated provided any early evidence of arterial 
degeneration is determinable. Every case of angina pectoris should 
be given the benefit of an antiluetic treatment. If the patient is 
manifestly neurotic then appropriate hydro-therapeutic medicinal 
and rest treatment, as described in the Section on Gastric Neuro- 
ses, should be instituted. 

As a means of prophylaxis the diet should be arranged in such 
a way that all principles capable of exciting the heart and raising 
the blood pressure are eliminated. Meat extracts and bouillons, 
raw, rare, cured and smoked meats, internal organs, tea and coffee 
should be forbidden because they contain extractives (purin bod- 
ies) that notoriously irritate the heart. Alcohol should be used 
with the greatest care, and smoking, even prolonged sojourn in 
a smoke-laden atmosphere, should be interdicted. Very hot and 
very cold beverages, spices, carbonated waters, should all be for- 
bidden and all distension and overloading of the stomach care- 
fully avoided, as otherwise reflex and mechanical irritation of the 
heart from the stomach may result. Other exciting causes to be 
avoided are sudden physical exercise, and especially quick move- 
ments of the left arm and left upper extremity. 

Unfortunately, the majority of cases of true angina pectoris are 
not recognized until the degeneration of the aorta and the coronary 
arteries has become irremediable. In such cases one is limited to 
regulating the patient's mode of life in such a way that all causes 
that can notoriously precipitate an attack are eliminated. If one 
could begin early, even with the prophylactic treatment, much 
would be gained, but unfortunately early manifestations of angina 
pectoris are usually misinterpreted, owing to the mild and tran- 
sitory character of the attacks, and above all, to the peculiar ten- 
dency of anginal pains to radiate into remote parts of the body, 
thus simulating neuralgias of various parts, lumbago, renal and 
hepatic colic or gastralgia. 

For all these reasons the treatment of angina pectoris is in 
most cases symptomatic and limited to aborting or relieving the 
paroxysms. The pain is excruciating and the sense of impending 
death horrible. The ordinary analgesic remedies are altogether too 



DISEASES OF THE CIRCULATORY APPARATUS 



319 



Cardiac tonics 
in low pres- 
sure type of 
angina 



slow in their action to have a place in the treatment of acute at- 
tacks of angina pectoris. As hypertension is present in most cases 
of angina pectoris the use of yaso-dilators is generally indicated. 
Here the character of the pulse and, above all, of the second aortic 
sound, should be carefully but quickly studied. If the pulse pos- 
sesses the characteristics of a high tension pulse, and if the second 
aortic sound is markedly accentuated, then the use of vaso-dila- 
tors and anti-spasmodics is always indicated. 

This study of the heart and blood pressure need, generally, 
only be performed during the first attack, chiefly to determine 
whether one may not possibly be dealing with a case of angina 
pectoris due to advanced myocarditis, or to aortitis without gen- 
eral arterio-sclerosis; for, in such cases the anginal attack may be 
due to, or may be complicated by, acute dilatation of the heart, 
with low arterial tension, as indicated by a weak second aortic 
sound, possibly murmurs (due to relative, i. e., muscular insuf- 
ficiency), a correspondingly low radial pulse and a weak apex 
beat. In this latter class of cases treatment directed against high 
tension is wrong; digitalis and other cardiac tonics and pressure- 
raising remedies are indicated, and not vaso-dilators ; the latter, 
in fact, do much harm, fail to relieve the symptoms, and may even 
determine death. 

Excepting in this comparatively rare class of cases, however, 
the nitrites are the remedy of choice. Amyl nitrite is deservedly 
the most popular remedy in angina pectoris. The drug is best 
dispensed in glass pearls containing three to five drops of amyl 
nitrite; patients suffering from angina pectoris should carry these 
pearls with them. Upon the appearance of the attack or of pre- 
monitory symptoms, such as pain radiating into the left arm, one 
of these pearls should be broken in a handkerchief and the vapors 
inhaled. The vaso-dilator effect becomes apparent almost instan- 
taneously, the face becomes flushed and the head feels full. If 
the attack is not stopped by the first inhalation, two, three or four 
pearls full of amyl nitrite should be inhaled at short intervals. 

One of the new remedies that is very highly spoken of is theo- 
bromin. It should be administered in doses of 0.5 g. twice daily. 
It produces blood-vessel dilatation and aids sclerotic vessels whose 
musculature is not yet degenerated; in this way ischemia of the 
regions supplied by the sclerotic vessels is prevented. In cases of 
arterio-sclerotic dizziness, fainting and headache, the remedy is of 
particular value. 

If this treatment fails to stop the agonizing pain, then re- Morphine 
course must be had to morphine, a drug that acts favorably in 
this condition, both by its vaso-dilator effect and its tendency to 
reduce the blood pressure. It should be given hypodermically, in 



Nitrites 
Amyl nitrite 



Theobromin 



320 



DISEASES OF THE CIKCULATORY APPARATUS 



Theocin 
Chloroform 



Applications 
to the pre- 
cordium 



Interim 
treatment 



Nitroglycerin 



doses of at least one-fourth to one-half grain (0.016 to 0.03 gm.) 
repeatedly. Theoretically, repeated doses of morphine are contra- 
indicated in cases of general arterio-sclerosis suffering from angina 
pectoris, in which there is arteriosclerotic degeneration of the kid- 
neys, because, under these circumstances, the drug is eliminated 
so slowly that a dangerous cumulative effect may be produced; but 
this will be a rare event. Inasmuch as morphine exercises its influ- 
ence very much more slowly than amyl nitrite, it is best to admin- 
ister a hypodermic of morphine as soon as the attack begins and 
while the amyl nitrite is being inhaled, for in this way valuable 
time may be saved. 

One of the best remedies to prevent the attacks is theocin 
natr. acet. 0.4g, to be taken every morning after breakfast. 

In case neither amyl nitrite nor morphine relieve the pain, then 
chloroform should be given, preferably by inhalation. This is, 
of course, a somewhat precarious procedure in any form of heart 
disease and hence this plan should only be adopted as an extreme 
emergency measure. 

Locally, hot applications, poultices or a mustard plaster to 
the precordial region may be of some benefit; counter-irritation 
of this kind should always be attempted, but only in addition to 
the other measures enumerated. 

In the interim between attacks, and in a sense as a prophylac- 
tic measure, nitroglycerin and nitrites may be given; to be effi- 
cacious, however, they should be given continuously. Nitrogly- 
cerin may be administered either in the form of one one- 
hundredth to one one-hundred-and-fiftieth grain tablets, two or 
three times a day, or preferably in the form of a one per cent, al- 
coholic solution, beginning with one drop of this three times a 
day and increasing the dose a drop every four or five days until 
flushing and headache appear. The dose should then be reduced a 
drop or two and the patient kept continuously on this amount. 
From time to time the dose should be increased until flushing and 
headache appear; and it will be found that after a time more can 
be tolerated than at the beginning. 

For prolonged use the following prescription is practical : 



s 



Lig. trinitrini, 
Tinct. cardamomi comp., 
Spir. chloroformii, 
Aqua ad, 

This amount to be taken each day, in the morning, in half a 
glass of water. 



0.06 

2.00 

0.60 

30.00 



DISEASES OF THE CIRCULATORY APPARATUS 321 

In case of marked cardiac weakness 0.03 of citrate of caffein 
should be used in place of the spirits of chloroform in the above 
prescription. 

A preparation of nitroglycerin that has recently attained well Erythrol 
deserved popularity is erythrol-tetranitrate. This remedy grants 
a more prolonged vaso-dilator effect than nitroglycerin. The fall in 
the blood pressure begins about half an hour after its administra- 
tion and usually persists for three or four hours. It may either be 
given in tablet form in doses of one-twelfth grain (5 mg.) every 
four hours, or in the form of drop doses of a concentrated solu- 
tion by mouth. Here, again, the appearance of flushing and head- 
ache indicates whether or not too much is being given. 

The nitrites, finally, should be administered in doses of three Nitrites 
grains (0.15 gm.) of sodium nitrite or potassium nitrite, three 
times a day, in milk or water ; or the formula of Lauder Brunton, 
given in the Section on Arteriosclerosis may be used to advan- 
tage. The use of iodide of potash has alreadv been mentioned Iodide of 
, " potash 

above. 

Seizures of pseudo-angina pectoris, due to functional nervous Pseudo-angi- 
disorders, and without evidence of arterio-sclerosis or myocarditis, 
can often be successfully treated by cold and pressure over the 
precordium, and a strong mental suggestion. During the paroxysm 
the administration of a teaspoonful of ether often relieves at once. 
In the interim the underlying neurosal element must be attacked, 
and all those general prophylactic measures instituted that are 
employed in true angina pectoris. 



PALPITATION. 

The disagreeable subjective character of palpitation makes it Introductory 
one of the most important symptoms to treat ; for patients are apt 
to worry more about it than about severe organic heart lesions 
that do not give rise to symptoms that are so noticeable. Palpi- 
tation may occur in organic heart disease, but more commonly it 
is present when the heart is organically intact. In few conditions 
does successful treatment depend so much on a careful diagnosis. 
Organic disease of the heart, especially fatty degeneration, dilata- 
tion and disease about the aortic valves, should always be care- 
fully looked for. Congenital smallness of the heart and narrowing 
of the arteries are also important findings. Palpitation in or- 
ganic heart disease is always a sign of cardiac weakness and oc- 
curs chiefly when more work is suddenly thrown upon the heart 
than its reserve force can meet. 



322 



DISEASES OF THE CIRCULATORY APPARATUS 



Functional 
palpitation 



Organic ner- 
vous disease 



Exophthalmic 
goitre 



Anemia and 
malnutrition 



Chlorosis 



Early tuber- 
culosis 



Nephritis 



Intoxications 



Neurasthenia 
and hysteria 



Reflex causes 



In the majority of cases there is merely over-irritability of 
the heart and its ganglia without heart lesions, possibly over- 
action of the accelerator nerves of the heart (the sympathetic), or 
defective action of the inhibitory nerves (the vagus). These per- 
versions of the action of the heart muscle and of the nervous ap- 
paratus of the heart may be purely functional, or they may be due 
to organic nervous disease. Hence particular care should be exer- 
cised to search for disease of the sympathetic or its ganglia, and 
for disease of the central nervous system. To the same category 
also belong early cases of exophthalmic goitre; so that in every 
case of palpitation, the eyes and the thyroid should be carefully 
examined for evidence of Graves' disease. Inasmuch as exoph- 
thalmic goitre occasionally appears without exophthalmos, and 
without goitre, the minor symptoms of this affection (the tremor, 
sweating, lid-signs, etc.) should be carefully looked for. 

Palpitation may also be a part phenomenon of anemia or 
chronic malnutrition in which there is irritable weakness of the 
nervous apparatus governing the heart's action. Very important 
in this respect is chlorosis, for here, as shown in another chapter, 
we have aside from the anemia, an unstable nervous system and 
very commonly congenital smallness of the heart and of the arte- 
rial capacity. 

In every case of palpitation the apices of the lungs should al- 
ways be carefully examined for evidences of early tuberculosis, 
for it is well known that in apical tuberculosis palpitation, of the 
heart is very common. Whether this is due to a special toxemia 
or to irritation of the sympathetic fibres in the neck is undeter- 
mined. In nephritis., too, especially in the carclio-vascular type 
of renal disease (Bright's disease), palpitation is a common sign, 
hence the urine should always be carefully investigated for the 
presence of renal elements, or albumen, and for renal inadequacy. 

Certain intoxications, notably by tea, tobacco, coffee, alcohol 
and even heart tonics (digitalis, strophanthus, strychnia, when 
employed injudiciously), can all cause palpitation. 

Finalh T , there is a purely neurotic form that develops on the 
basis of neurasthenia or hysteria. Here exciting causes must be 
very carefully looked for. These may be external and consist 
of some sudden emotional shock, a fright, a loud noise, or a flash 
of light, etc., or they may be internal and reflex in character; thus 
indigestion, especially when associated with gaseous fermentation 
or flatulency, intestinal parasites, abdominal adhesions, gastro and 
enteroptosis, disorders about the genital apparatus, especially the 
ovaries and uterus, hemorrhoids and abdominal plethora in general, 
may all reflexly, in predisposed subjects^ irritate the heart in such 
a way that palpitation is produced. 



DISEASES OF THE CIRCULATORY APPARATUS 



323 



To prevent the attacks of palpitation the underlying cause must 
be treated. In palpitation resulting from over-exertion or fatigue, 
especially in individuals whose heart is congenitally small or whose 
arteries are narrow, or in subjects with a thorax paralyticus or a 
phthisical habit, the amount of exercise must be carefully regu- 
lated. Such individuals must learn how much physical exercise 
they can stand without developing palpitation and should careful- 
ly train the heart to increased labor by means of Schott and Oertel 
exercises or hydriatic means. Very hot baths, and, above all, 
Turkish baths, should be forbidden such subjects and the use of 
coffee, tea, alcohol and tobacco should be restricted or stopped. In 
phthisical patients particularly the administration of heart tonics 
and analeptics should be carried out very conservatively and pre- 
ferably reserved only for emergencies. 

In palpitation occurring in organic disease of the heart in sub- 
jects who are not neurotic, the treatment is synonymous with the 
treatment of the underlying cardiac disorder. One should constant- 
ly remember that palpitation is often an early sign of valvu- 
lar disease so tbat the diagnosis of nervous palpitation should 
always be made very guardedly. Heart tonics judiciously admin- 
istered according to the principles described under compensated 
valvular disease, especially when combined with drop doses of the 
tincture of aconite, will relieve the palpitation in these cases. 

If the palpitation is purely neurotic in type without organic 
disease of the heart a lest cure and appropriate hydro-therapeu- 
tic measures, as lukewarm baths ? are particularly valuable in re- 
ducing the frequency of the attacks. Suggestive therapy also 
helps. The patients should be carefully instructed in regard to 
the purely functional character of their heart symptoms and 
should be encouraged not to worry. All emotional or mental 
strain should be strenuously avoided. The patients should be in- 
structed to reduce the use of tea, coffee, alcohol and to stop smok- 
ing. Particular care should be taken to find possible reflex 
causes for the palpitation, and for this reason, the genital ap- 
paratus, the rectum and the nose should be carefully examined 
and any abnormalities corrected; intestinal parasites should be 
looked for and removed; the function of the stomach and intes- 
tine should be regulated. The exact arrangement of the diet 
must depend on the functional state of the digestion and, for 
this reason, careful analyses of the stomach contents should be 
made from time to time and treatment instituted accordingly. No 
general rules can be formulated except that the meals should be 
small in order to prevent over-loading and distension of the stom- 
ach and should contain little carbohydrate in order to forestall 
fermentative dyspepsia, flatulency and meteorism. The food 



Prophylaxis 



Exercise 



Bathing 



Treatment of 
palpitation in 
organic heart 
disease 



Neurotic type 
Rest cure 



Diet and neu- 
rotic cases 



324 



DISEASES OF THE CIRCULATORY APPARATUS 



Drugs in neu- 
rotic cases 



Valerian 
Bromides 
Nux vomica 



Symptomatic 
treatment of 
the paroxysm 

Deep breath- 
ing 

Counter-irri- 
tation of the 
nasal mucosa 
Faradization 
of the vagus 

Counter-irri- 
tants to pre- 
cordium 



Cardiac 
stimulants 



Aconite 



should never be too hot nor too cold, nor should it contain strong 
spices. 

In purely neurotic cases valerian and bromides are the most 
useful remedies for continuous use. Sodium bromide in ten to 
fifteen grain doses, two or three times a day, combined with the 
ammoniated tincture of valerian, one to three drachms (4 to 12 
cc), and the tincture of nux vomica five to ten drops, is a useful 
combination; or the pill of the three valerianates (Goddell) may 
be used to advantage, viz.: 

Quinine valerianate, 

Iron valerianate, 

Ammonia valerianate, aa 1 gr. (0.06 gm.) 

M. Sig. One such pill two or three times a day. 

The treatment of the paroxysm does not differ materially from 
the preventive treatment, excepting that somewhat more energetic 
measures are employed. Any reflex stimulation of the vagus 
usually stops the paroxysm. This reflex stimulation may be pro- 
duced by instructing the patient to breathe deeply; or by the use 
of smelling salts or iodo-glycerin applied to the nose on a probe; 
or by an indifferent alkaline nasal spray. In very severe cases 
faradization of the vagus and neck, as described in the Section 
on Exophthalmic Goitre is often useful. 

Clothing that is tight about the chest and waist should be 
removed. A belladonna or mustard plaster may be applied to the 
precordial region. Better still is the application of cold in the 
form of an ice bag, for both the cold and the pressure 
upon the heart and, in hysterical cases, the suggestive effect, aid 
in quieting the heart; at the same time hot water bags may be 
applied to the feet and the legs vigorously rubbed. Some pa- 
tients of the neurotic type derive almost instantaneous relief 
from compression of the heart by means of a pelotte arranged like 
a truss, to be adjusted around the thorax as soon as palpitation 
occurs. Here, too, a suggestive element presumably plays an im- 
portant part. 

The medicamentous treatment in cases due to organic disease 
of the heart consists in the use of strong cardiac stimulants, hot 
coffee, brandy, digitalis, camphor, ether, ammonia. The special 
treatment of palpitation in compensated aortic insufficiency has 
already been discussed. If the blood pressure is very high, amyl 
nitrite may be inhaled. 

If there is no organic disease of the heart and no dilatation 
from over-exertion, then the tincture of aconite in drop doses 
every hour is the most efficacious remedy. Often in such cases a 



DISEASES OF THE CIRCULATORY APPARATUS 



325 



few whiffs of chloroform, or one-fourth grain of morphine, hypo- 
dermicalry, also stop the paroxysm promptly. Sodium bromide 
and chloral, ten grains of each, repeated every hour and a half or 
two hours for two or three doses, will prevent the recurrence of 
the attack. This combination, too is valuable as a prophylactic 
measure in nocturnal palpitation. Here, if given just before re- 
tiring, the restlessness and sleeplessness are allayed and the noc- 
turnal attack of palpitation prevented. 

In purely hysterical cases the ammoniated tincture of valerian, 
one to three drachms (4 to 12 cc.) or asafetida, preferably given 
as the aloes and asafetida pill in four to eight grain doses, oc- 
casionally stop the paroxysm. That a strong mental suggestion 
should be attempted in all cases of hysterical or neurasthenic pal- 
pitation need hardly be repeated. Very often a command on the 
part of the physician to exercise self-control will stop the palpi- 
tation. In other cases the repeated assurance that there is no 
danger, or soothing suggestions and, in extreme cases, hypnosis, 
may be more effective than a command. 

Bornyval, the isovalerianate of borneol, is indicated wherever 
valerianates are employed, that is, particularly in functional dis- 
orders of the nervous system, as in hysteria, neurasthenia, trau- 
matic neuroses and secondary neurasthenias; furthermore in dis- 
ordered conditions of the circulatory apparatus based upon neu- 
rotic vasomotor disturbances, especially in circulatory disorders 
occurring during menstruation and the menopause. No toxic 
symptoms have ever been seen from the use of this drug and all 
patients tolerate it very well. 

If the bowels are constipated when the attacks come on, or 
if there is evidence of much abdominal plethora (hemorrhoids), 
meteorism or flatulency, a brisk saline cathartic, i. e., a tablespoon- 
ful of sodium or magnesium sulphate and a colonic flushing should 
be given. If there is evidence of acute distension or dilatation of 
the stomach, then evacuation of the stomach contents through a 
stomach tube followed by lavage (see index) often suffices with- 
out further medication to stop the paroxysm of palpitation. 



Chloroform 
Morphine 
Sodium bro- 
mide 
Chloral 



Valerian 
Asafetida 



Bornyval 



Catharsis 



Lavage of the 
stomach 



ARRHYTHMIA. 



Irregular heart action, abnormal slowness or rapidity of the 
heart, may either accompany a variety of organic disorders of 
the heart and arteries, chiefly myocarditis and dilatation occur- 
ring in the course of infectious diseases or of arterio-sclerosis ; 
or they may be a part symptom of some organic lesion of the ner- 
vous system or of a functional neurosis; or, finally, they may be 



326 DISEASES OF THE CIRCULATORY APPARATUS 

the result of intoxication by alcohol, tobacco, coffee, lead, etc. The 
different varieties of irregular heart action, viz., intermittent, 
paradox, bigeminal and trigeminal pulse, embryo-cardia, brady- 
cardia, tachycardia, gallop-rhythm and delirium cordis must all 
be carefully analyzed and the underlying causes determined. If 
due to valvular lesions or myocardial or arteriosclerotic changes, 
these conditions should be treated as described under those dis- 
orders. If due to cerebro-spinal disease (syphilis, sclerosis, gum- 
ma, hemorrhage), then large doses of iodides should always be 
given a trial. If due to a functional neurosis, then this should 
be treated, at the same time reflex causes in different organs should 
be sought for and removed. The toxic varieties self -evidently call 
for the withdrawal of the toxic agent. 

It will be seen, therefore, that the different forms of irregu- 
lar heart action call for similar causal treatment as palpitation. 
The symptomatic treatment is altogether identical with that of 
palpitation; in fact, the combination of arrhythmia and palpita- 
tion, especially tachycardia and palpitation, is the rule. Eor the 
details of this treatment I, therefore, refer to the Section on 
Palpitation. Slow pulse (bradycardia), it may be remembered, 
finally, is often a physiological phenomenon, in no way endangers 
the life of the patient and calls for no special treatment. 



CHAPTER V. 

DISEASES OF THE DUCTLESS GLANDS. 

ORGANOTHERAPY: HISTORICAL REVIEW AND CRITIQUE. 

There is little that is pleasing in the past of organotherapy ; the History of 
present offers only scanty satisfaction from a practical standpoint, organotherapy 
The history of organotherapy, like the history of every other chap- 
ter in therapeutics, begins with a jumble of obscurities. Organo- 
therapy originated in the crudest empiricism. Everything was 
tried, and the more bizarre the product the greater the efficacy 
postulated for it. Premonitions of the homeopathic law of similars 
are discoverable early; head preparations for headache; heart ex- 
tract for heart disease; stomach contents, stools for digestive dis- 
turbances; kidney extracts for renal difficulties, et id omne genus. 
Often will be encountered the peculiar perversions of logic illus- 
trated more clearly in the gastronomic field, viz.: Nightingales' 
tongues are hailed by the Eoman epicures as a delicacy, for what 
produces a beautiful sound should produce a pleasant taste; pow- 
dered pearls are recommended as a flavor, for what is pleasing to 
the eye should be pleasing to the palate. What was difficult to 
secure in those early days from dead human beings or decaying 
animals, what was especially disgusting, putrid, nauseating; all 
that was endowed with healing virtues in equally disgusting, nause- 
ating diseases, as mysterious as the products used to combat them. 

The "Papyrus Ebers," the oldest existing medical manuscript, 
described a variety of remedies derived from human and animal 
bodies. .Through the writings of Homer, Aretaeus, Democritus, 
Dioscorides, Galen, and many of the medieval authors, Guido de 
Chauliac, Burton (in his "Anatomy of Melancholy"), John 
Hunter, will be found references to organotherapy. Interesting 
preparations are recommended in the "New London Dispensatory" 
of 1677, where reference is made to tinctura cranii, essentia cranti 
humanis, spiritus cerebri humani for "debility ;" cor hominis, pow- 
dered, for epilepsy, and many other similarly absurd and bizarre 
products. 

Organotherapy, however, never acquired popularity, never Brown>-Sequard 
attained to the dignity of a therapeutic system, until the publica- and j» ternal 
tion by Brown-Sequard, in 1869, of his experiments with testicular 



328 



DISEASES OF THE DUCTLESS GLANDS 



Testicular 
extract 



Critique 



Methods 



Active prin- 
ciples 



extract (sue testiculare) and his formulation of the therapeutic 
effect of "internal secretions." Coming from so eminent and con- 
servative an authority, proclaiming the most startling results 
secured upon his own person, viz., "a return of vital energy and 
rejuvenescence with renewed and efficient peristalsis and control 
over the bladder and sphincter," it is not to be wondered at that 
the organotherapeutic method at once advanced into prominence. 
Add to this the sensational character of the claims advanced, 
amounting to nothing less than the restoration of youthful func- 
tions, of sexual potency, the arrest of senility, the discovery in 
other words of the "fountain of youth," and we can very well 
understand the hysterical acclaim that greeted this soi-disant dis- 
covery of Brown-Sequard in France. We have had a similar expe- 
rience recently with the claims of Metchnikoff . While practically 
nothing of value has come from orchitic therapy, still an immense 
stimulus was given to this form of investigation, with the result 
that we have today a small number of exceedingly valuable addi- 
tions to our therapeutic armamentarium, and above all a working 
theory that if logically pursued, carefully controlled and honestly 
founded on facts that are capable of full clinical verification, prom- 
ises to lead to big things in the near future. 

It is manifestly a precarious and an unscientific procedure to 
introduce substances of uncertain composition and unknown prop- 
erties into a sick organism without first determining their effect on 
the healthy body. Before organotherapy could be raised above the 
level of raw empiricism and could attain the dignity of a rational 
system of treatment, the power of organ extracts to influence 
physiological processes had to be studied. This problem was ap- 
proached in two ways, viz.: On the one hand, different animal 
preparations were administered to normal animals or human sub- 
jects and the effects determined ; on the other hand, different organs 
(chiefly ductless glands) were removed and the perversions of 
function that followed established. The knowledge, moreover, ob- 
tained from operative ablation of organs was in many instances 
supplemented by clinical observations on human subjects in whom 
spontaneous degeneration or atrophy of these organs had occurred. 
Organotherapy was finally rendered still more exact by the dis- 
covery and isolation of "active principles" that possessed all the 
specific properties of the organs from which they were derived, and 
that could in some instances be advantageously administered in 
the place of the crude extracts. 

Whatever may be accomplished in the future with organotherapy 
must be based upon still more accurate physiologic knowledge than 
we possess today. This line of research is among the most fascinat- 
ing and offers the greatest promise of important discovery. Notable 



DISEASES OF THE DUCTLESS GLANDS 329 

advances have been made in many directions, but the work has been 
very disconnected and shows a deplorable lack of systematic pro- 
gression and concentrated effort. Much that has been found owes 
its discovery to chance, to random trying, often actually to errors 
in technic; I refer as an illustration of the last to the knowledge 
we have acquired from surgical accidents in thyroidectomy of the 
role of the parathyroids in the pathogenesis of tetany. 

A comprehensive and complete investigation of the physiology 
of the glands furnishing "internal secretions," singly and in con- 
catenation, must proceed along the following Hnes; simple prelim- 
inary steps in the right direction having already been taken. 

A gland, we will say, the pancreas^ must be removed in its The basis of 
entirety and the effect of this ablation determined. In a second or g an °tnerapy 
series of experiments extracts of the gland must be introduced into 
a healthy organism of the same species, or, if possible, the gland or 
portions of the gland must be ingrafted and again these effects 
studied. Finally, after ablation of the gland, extracts must be 
injected or grafts made in the same animal and these effects 
studied. This should yield definite information in regard to the 
effect (1) of the absence of an internal secretion; (2) of the admin- 
istration of an internal secretion in excess; (3) of the power of an 
internal secretion to replace a removed gland or to act as a substi- 
tute when it is absent or its secretory function deficient. This is 
the first step ; all available information should be similarly secured 
for each of the ductless glands singly, for the adrenals, the thyroid, 
the spleen, the ovaries, etc. 

The next step must concern itself with identically similar 
studies with two glands. To illustrate: A study of the pancreas, 
we will say, and the adrenals implies (1) removal of the pancreas 
— injection of pancreas, injection of adrenals; (2) removal of 
adrenals — injection of pancreas, injection of adrenals; (3) removal 
both of pancreas and adrenals — injection of pancreas, injection of 
adrenals, injection of adrenals plus pancreas. 

The third step comprises the study of three glands, for instance, 
pancreas, adrenals, thyroid. It is unnecessary to specify the various 
possible combinations that must be studied. They are very numer- 
ous and we can outline the course of such a triple or quadruple or 
multiple study according to simple mathematical laws of transmu- 
tation and commutation. 

One would have to include in this study such organs as liver, 
muscle, lymph glands, etc., the complete removal of which is not 
compatible with life. Here the investigation would become less 
exact and approximate results only could be expected. The whole 
investigation, however, would partake of the character of a descrip- 
tive analysis. One should proceed without preconceived ideas, with- 



330 



DISEASES OF THE DUCTLESS GLANDS 



Limitations 
of organo- 
therapy 



Bloodforming 
organs 



Nerve tissue 



Kidney, liver 



Pancreas in 
diabetes 



out expectation of prescribed results, without reliance upon a priori 
conclusions or analogies. Only in this way can the truth be arrived 
at. There will be immense technical difficulties to be surmounted ; 
the studies will have to comprise the whole range of the manifold 
functions of the body and their perversions, will have to deal most 
explicitly with the intricate mechanism of the intermediary 
metabolism. But the immense task, best carried out as a collective 
investigation by many observers, for the lifetime of one investi- 
gator could not suffice to accomplish it, would be very much worth 
while. It would be the only reliable fundament for organothera- 
peutic endeavor, as soon, namely, as the facts discovered relative to 
the healthy organism could be applied equally systematically to the 
body diseased. 

To this day, owing to our inadequate preliminary knowledge, 
the therapeutic efficacy of organ injection and organ ablation is 
limited. With the exception of ovarian therapy in disorders of the 
menopause (natural or induced), of thyroid therapy in myxedema 
or athyroidism and in a definite class of simple goiters (where 
thyroid therapy constitutes a "rest cure," I imagine, for an over- 
taxed gland enabling it to gradually "exercise" up to the demands 
made upon it), with the exception, furthermore, of suprarenal 
therapy in cases where local vaso-constriction or a general rise in 
blood-pressure is desired, the achievements of gland therapy are 
very scanty. 

Spleen, lymph glands and bone-marrow (collectively the blood- 
forming organs) have been used extensively in blood diseases with 
results that are quite ambiguous. A polynuclear leucocytosis seems 
to be the main effect due, no doubt, to the large amount of nuclein 
that these tissues contain. No specific action has so far been 
discovered. 

Nervous tissues employed in various psychoses, functional or 
organic nervous diseases, seem to produce no determinable effect as 
soon as the large element of suggestion is ruled out. Much work 
has recently been done with extracts from kidneys in nephritis and 
uremia, with liver extracts in uremia and hepatic insufficiency; 
this field is promising, but nothing of a positive character has so 
far been discovered that would warrant the use of these prepara- 
tions in the treatment of these diseases. 

Pancreas and its preparations have also been found quite inef- 
fective in diabetes, although here theoretically, at least, was every 
reason to expect results. Experiments with pancreas-muscle ex- 
tracts seemed to demonstrate the power of the latter to reduce the 
sugar excretion. I even became so far convinced of the efficacy of 
such extracts in influencing diabetic glycosuria that I published a 
preliminary report on this therapy several years ago; numerous 



DISEASES OP THE DUCTLESS GLANDS 



331 



quite negative results obtained since that time have, however, forced 
me to recede from the belief originally maintained. That pancreas 
is, of course, effective in replacing deficient external secretion of 
the gland in obstructive or obliterative disorders of the pancreas or 
its channels is self-evident; this, like the use of bile or bile-acids 
in hepatic disease, is certainly a form of organotherapy, and a very 
useful one, but not properly germane to the aspect of the subject 
under discussion tonight. 

So far, then, the field belongs rather to the metaphysician than 
the physician, to the dreamer rather than the logician. Some re- 
markably ingenious webs of hypothesis have been woven around 
and about this subject. However fascinating and seductive, even 
convincing, they appear, they have so far not attained the dignity 
of a safe working theory. 



DISEASES OF THE THYROID GLAND— MYXEDEMA 
AND CRETINISM.* 

The function of the thyroid gland is either nutritive or anti- 
toxic, i. e., it either supplies something to the blood that is neces- 
sary to normal life or it removes something from it that is harmful. 

Removal of the thyroid is followed within a few days, or after 
a longer time (as late as nine months), by anemia and oligemia. 
There is often an initial rise of temperature, usually followed by 
a descent to subnormal. In young animals the growth of the bones 
ia retarded and various trophic disturbances develop, the rate of 
respiration increases, a variety of nervous phenomena are observed 
that may be either irritative or depressive in character, viz., about 
the motor sphere, fibrillary twitching of the muscles followed later 
by tetany, contractures or paresis ; and in the sensory sphere, first 
hyperesthesia and later diminished sensibility ; and about the heart 
palpitation and tachycardia. 

Clinically, a similar syndrome is presented in myxedema 
(synonyms, sporadic or endemic cretinism) and in cretinism 
(synonyms, infantile or fetal myxedema, myxedematous idiotism, 
athyreosis chronica), as well as in operative removal of the thy- 
roid gland (cachexia thyreopriva if the normal gland is removed, 
cachexia strumipriva if the diseased gland is removed). The con- 
clusion is, therefore, self-evident that these diseases are due to sup- 
pression of the thyroid function. 

Here, therefore, the administration of thyroid gland is the sov- 
ereign remedy and the results obtained from this treatment are 
among the most brilliant achievements of modern medicine. 



Effects of re- 
moval of the 
thyroid 



Myxedema 



Thyroid ther- 
apy in cre- 
tinism 



♦Portions of this chapter are quoted from my article on Organo- 
Therapy in "The Reference Handbook of the Medical Sciences" 



332 



Diseases oe the ductless glands 



In operative 
myxedema 



In endemic 
cretinism 



Administration 
of thyroid 



The best results are seen in cretinism. Here the skin soon be- 
comes soft and moist, the bloating disappears, healthy growth of 
the bony structures, of the hair and of the soft tissues is stimulated, 
normal development of the teeth sets in and the mental condition 
improves, so that the patients change from apathetic semi-idiotic 
children to energetic and active individuals. The younger the sub- 
ject, the better apparently the result, although all ages seem to re- 
act favorably. In a very small proportion of cases thyroid is with- 
out result, and one or two cases are recorded in which the disease 
was aggravated. The unsuccessful cases constitute not quite two 
per cent, of all those reported in the literature. As it is not ex- 
cluded that in many of these instances the thyroid preparations 
employed were worthless, this is a remarkable showing and one 
that warrants the use of thyroid in all cases of myxedematous dis- 
ease in children. Similarly good results are seen in operative myx- 
edema ; and in many instances the disagreeable phenomena follow- 
ing ablation of the thyroid gland could be prevented by the admin- 
istration of thyroid preparations. In the endemic cretinism of 
adults the results are not quite so uniform, for in a certain propor- 
tion of the cases only the main symptoms are relieved while the 
minor and probably secondary manifestations persist; thus the 
edemas may promptly recede while the cachexia and the phenomena 
that are consecutive to the anemia in various organs remain unin- 
fluenced by thyroid medication. 

It is usually necessary to continue the administration of thyroid 
for some time; if the remedy has to be stopped temporarily, for 
reasons that will be presently discussed, then its use may be re- 
sumed again, from time to time, otherwise a recurrence of the 
symptoms is apt to supervene. This is due to the fact that the use 
of thyroid is merely a substitution therapy. In cases in which im- 
provement is maintained for considerable periods after the admin- 
istration of the remedy has been stopped, we must assume that the 
organism has stored away a certain reserve amount of the organ 
material. As soon as the latter becomes exhausted, symptoms of 
myxedema reappear and the recurrence of typical phenomena again 
calls for the administration of thyroid. 

In the infantile form a course of thyroid carried on for a suf- 
ficient length of time, either continuously or intermittently, often 
leads to a permanent cure, so that the drug can ultimately be dis- 
continued. This must be attributed to the fact that the substitu- 
tion of thyroid, by relieving the defective thyroid of an amount of 
labor that it was unable to perform, has enabled it to develop up 
to the demands of the growing organism and ultimately to assume 
its normal function; such a favorable result, however, is exceed- 
ingly rare. 



DISEASES OF THE DUCTLESS GLANDS 



333 



Not infrequently, as indicated above, a congeries of distressing 
symptoms follows the prolonged use of thyroid that may call for 
an interruption of the treatment. The manifold effects that are 
attributed to thyroid feeding have been grouped under the name 
of thyroidism (or hyperthyroidism). They are characterized in 
extreme cases by pronounced tachycardia, palpitation, sweating, 
tremor and emaciation ; the latter being due to increased intracellu- 
lar oxidation and "accelerated" (?) metabolism, concerning chiefly 
the proteids and fats of the body, and manifesting itself by an 
increased excretion of nitrogen, phosphorus and chlorine. Fever 
and glycosuria are also occasionally observed. The patients de- 
velop an enormous appetite and thirst and often complain of head- 
ache, nausea, vomiting and weakness. It is doubtful whether these 
symptoms are due exclusively to the thyroid or whether they are 
due in part to certain toxic products contained in most thyroid 
preparations; for especially dried thyroid powder frequently con- 
tains ptomapeptones and peptotoxins that are highly poisonous 
even in minute quantities. This assumption is borne out by the 
fact that thyroidin (see below) rarely produces these symptoms, 
whereas dried extracts or the fresh ( ?) gland often produce them. 

Fortunately, we are able in cases that develop symptoms of 
thyroidism to counteract most of these disagreeable effects by the 
administration of small doses of arsenic, e. g., three to five drops 
of Fowler's solution given during the day. The results of this 
arsenic treatment are really remarkable, and it is probably always 
a safe plan, if a prolonged thyroid treatment is contemplated, to 
give Fowler's solution in the above dose from the beginning. 

Various preparations of the thyroid gland are employed. 
Bircher, in 1889, first implanted a piece of human thyroid gland 
under the skin and in this way produced a prolonged thyroid 
effect with a brilliant result. Grafting of sheep's thyroid has been 
tried in operative myxedema with good effect^ but none of these 
methods is, of course, practical. Different extracts of thyroid have 
been prepared with glycerin alone, or with glycerin and carbolic 
acid and thymol; these are administered hypodermically. Another 
hypodermic preparation is made by extracting thyroid with car- 
bolized physiological salt solution and sterilizing the extract by 
filtering it through clay filters under high pressure with carbonic 
acid gas (method of d'Arsonval). Many clinicians advise the use 
of the fresh gland, raw, by mouth (one-eighth to two sheep's thy- 
roids a day). Good results are also claimed from the administra- 
tion of the boiled organ, which is more palatable than raw thyroid. 
Finally, thyroid gland may be finely chopped and given in a clysma 
by rectum. 



Distressing 
symptoms fol- 
lowing thyroid 
medication 



Thyroidism 



Arsenic in 
thyroidism 



Preparations 
of thyroid 



334 



DISEASES OF THE DUCTLESS GLANDS 



The most deservedly popular preparations, nowadays, how- 
ever, are compressed thyroid tablets made from the dessicated 
gland. These are less disagreeable to administer than the other 
preparations mentioned and, if manufactured by a reliable house, 
enable the physician accurately to determine the dose. True, 
very little is known of the amount of active principle which they 
contain, but the same objection applies to all the other prepara- 
tions. As it is essential to strictly individualize in thyroid medi- 
cation, it is at all events of advantage to know that the qualitative 
and quantitative composition of the tablets is approximately uni- 
form. As the fresh gland furnishes about 27 per cent, of dry 
powder, each unit of powder corresponds to about four times its 
equivalent in fresh gland. Manufacturers of thyroid tablets usually 
indicate the amount of thyroid powder contained in each tablet. 
The common average dose of the dessicated powder is from one to 
five grains three times a day. 

The active principle of thyroid gland is iodothyrin* or thy- 
roiodin (not thyroidin which is a name for the extract of the 
gland), a proteid body containing over 9 per cent, of iodine. It 
may be used in the place of the fresh thyroid extract but seems 
unable to replace it in all cases. The dose is from one-third to 
one-half grain (0.02-0.03 gm.) two or three times a day. 

EXOPHTHALMIC GOITRE. 



Thyroidism 
and exoph- 
thalmic goitre 



Many of the symptoms of exophthalmic goitre (Graves' dis- 
ease, Basedow's disease) resemble in their cardinal aspects the 
syndrome previously described as thyroidism or hyperthyroidism, 
so that this disease is held to be due to excessive activity of the 
thyroid gland. As a matter of fact many of the symptoms of 
Graves's disease are attributable to an increased secretion of the 
thyroid gland. Other features can be explained by a qualitative 
perversion of the thyroid function. In addition, however, there are 
a variety of signs in this disorder that can only be explained by 
some functional derangement of the cervical sympathetic and its 
ganglia, an idea that is borne out histologically by the occasional 
discovery of lesions in this portion of the nervous system as well 
as in the central nervous organ, especially in the corpora resti- 
formia. 

The disorder of the thyroid in Graves's disease is not due to a 
compensatory hypertrophy of the gland caused by relatively 
excessive demands for thyroid secretion as in simple goitre, but 



*It would be of no practical value to discuss in this place the many 
other so-called "active principles" that have been isolated as, e. g., thy- 
reoglobulin, iodoglobulin, etc., etc. 



DISEASES OF THE DUCTLESS GLANDS 335 

it is due to an absolute functional hyperactivity (and ^activity) 
with vascular engorgement which leads to the entrance into the 
blood stream of an excessive quantity of the internal secretion of 
the gland. 

To supply thyroid extract in this disorder is, therefore alto- Fallacy of 
gether irrational and paradoxical. It is unfortunate to record that {Separations 
this remedy is, nevertheless, extensively employed' in this disease in this disease 
either empirically or from ignorance of the physiological action 
of thyroid extract. There can be no doubt that thyroid always 
does harm in this disease. There is no case on record of true 
Graves's disease in which thyroid medication was of benefit, and 
there are many cases on record in which it did serious harm. 

Of recent years, the serum and the milk of thyroidectomized Serum of thy- 
animals have been utilized in the treatment of Graves' disease, animals 3 " 112 
The principle underlying this method is at least based on more 
sound physiological reasoning. The results obtained from the use 
of these preparations are for the present, however, ambiguous, and 
must be interpreted carefully and with great conservatism, 
especially as Graves's disease usually runs its course with many 
spontaneous remissions and intermissions. It is best, therefore, 
to suspend judgment for the present in regard to their efficacy. 

Thymus has been used in Graves's disease with some good Thymus 
results. Again, however, spontaneous remissions and intermis- 
sions must be included in the calculation. As no one has ever 
reported any bad effects from the use of thymus, the preparations 
made from this gland may be tried in conjunction with other 
measures to be presently described. Eaw thymus, from sheep, 
may be given, or thymus tablets. The dose of the latter should 
vary from five to fifteen grains two or three times a day. 

The most important general measure to be employed in the Rest 
treatment of exophthalmic goitre is rest, both physical and psy- 
chical, for the disease is frequently characterized by emotional 
excitement or depression; therefore the patients should live under 
conditions and among people where they are safe from emotional 
excitement, worry, anger and nervous strain. In most cases it 
is well to take the patient away from home, friends and relations 
for a period of several weeks. A change of scene alone often works 
wonders. 

If a case of Graves's disease is sent to a resort, a low altitude Climate and 
should be selected, for it is a common experience that elevations a l U c 
over two thousand feet frequently induce severe palpitation. Life 
at a high altitude, moreover, stimulates the nervous system, and 
in view of the hyper-excitability of the whole nervous apparatus 
in these cases, such stimulation should be avoided. The sea shore 
is never good for these cases, for life by the ocean is detrimental 



336 DISEASES OF THE DUCTLESS GLANDS 

both on account of its stimulating effect upon the nerves and on 
account of the deleterious effect it exercises upon anemic patients 
in general. 

Diet There is much controversy in regard to the proper diet. Many 

clinicians recommend a diet consisting largely of vegetables, 
cereals, fruit and milk, with the minimum of meat and eggs. Per- 
sonally I have seen better results from an abundant meat and egg 
diet combined with the above. In Graves's disease the general 
metabolism is usually very active and many of these cases rapidly 
emaciate. The question has not been definitely decided by careful 
metabolic studies whether the disassimilation of the fats or of the 
proteids is particularly increased; at all events there is almost 
invariably a more active proteid metabolism than normal, as mani- 
fested by the increased excretion of nitrogen. Consequently, severe 
cases of Graves's disease should ingest more than the normal 
amount of albumen, otherwise they will attack the proteids of 
their own tissues in order to make up the deficit. Above all things 
in this as in any other disease the albumen of the body must be 
protected and this can only be done by supplying a sufficient quan- 
tity of albuminous pabulum by mouth. The patients, as a rule, 
feel better and stronger and retain their weight if abundant proteid 
is allowed. It is necessary, of course, to strictly individualize in 
this respect and to take into consideration the tastes of the patient, 
his previous habits, the state of the digestion and of the kidneys 
in each case. The objection that a "meat toxemia" develops on 
such a diet is theoretically constructed and not borne out by facts. 

Electricity Electricity should always be given a trial in Graves's disease, 

for considerable advantage accrues to some cases from its use. The 
galvanic current is preferably used, although general faradization 
is recommended by some clinicians, particularly of the French 
school. If the galvanic current is employed a small ball electrode, 
connected with the anode, should be applied below the angle of 
the jaw and slight pressure exercised upwards and inwards. The 
other electrode should be a flat sponge or plate applied to the bacJc 
of the neck at the level of the lower cervical vertebra, that is, 
corresponding to the location of the lower cervical spinal ganglia. 
Often it is of advantage to change the direction of the current. 
The current in the beginning should not be stronger than one 
milliampere and should not be applied for more than three minutes 
at a time. Both sides of the neck should be galvanized at each 
fitting. Later, the strength of the current should be gradually 
increased to three or four milliamperes. At each sitting it should 
be slowly increased and then decreased. In this way not only 
the sympathetic, but also the various nerves of the neck that are 
in close proximity to it, especially the vagus and probably, to some 



DISEASES OF THE DUCTLESS GLANDS 



337 



extent, the upper portions of the spinal cord are reached by the 
electric current. Very often it will be found that this treatment 
properly carried out reduces the general nervousness of the patient 
as well as the palpitation and the tremor. Galvanization of the 
thyroid gland itself with a small sponge electrode is also often 
useful. 

Hydro-therapeutic means, unless they can be carried out under 
careful supervision in an institution, should be used guardedly. 
They have a place, however, in the treatment of Graves's disease. 
The exact choice of method will depend upon the presence or 
absence of severe degrees of anemia, of digestive disorders, of 
myocarditis or cardiac dilatation and upon the reactive state of 
the nervous system, notably the vaso-motors. At all events, severe 
hydriatic measures, i. e., extremes of heat or cold, should never 
be employed, but rather very mild, soothing measures. Most bene- 
ficial is immersion of the patient in water slightly below the body 
temperature, as described in the Chapter on Heart Disease. Salt 
may be added or carbonated waters may be used. The patient 
should lie perfectly still for five or ten minutes in the water, should 
then be rubbed dry with a rough towel, the surface of the body 
treated with alcohol and the patient immediately put to bed. In 
cases that are not very severe, the patients may be wrapped in a 
towel wrung out of lukewarm water, covered with woolen blankets 
and left in this packing for half an hour at a time. It is always 
best to leave the arms out of the packing, as otherwise a sense of 
restraint or uneasiness may be created that in these nervous and 
excitable individuals is decidedly detrimental. A Priessnitz com- 
press over the thyroid applied two or three times a day for an 
hour or two at a time sometimes acts beneficially. 

The medicamentous treatment of Graves' disease is not very 
satisfactory. If there is much anemia iron and arsenic should 
be given, as described under Anemia. The nervous symptoms 
must be controlled with bromides, the best preparations being the 
bromide of soda and the bromide of strontium, both given in doses 
of from ten to thirty grains (0.65 to 2.0 gm.) preferably in milk, 
three or four times a day. Monobromate of camphor, in ten grain 
doses (0.65 gm.) may also be given several times a day. If there 
is much cerebral excitement, hyoscine hydrobromate, in doses of 
one two-hundredths to one one-hundredth grain, preferably com- 
bined with bromides or with valerian, is useful. Another remedy 
that seems to act beneficially in Graves' disease is phosphate of 
soda. It should be given in thirty to sixty grain doses (2 to 4 
gm.) two or three times a day, in plenty of water. This drug 
seems to exercise its effect especially upon the nervous mechanism 
governing the heart. The best remedy for palpitation and tachy- 



Hydrotherapy 



Medicamen- 
tous treat- 
ment 

Iron 

Arsenic 

Bromides 

Camphor 

Hyoscine 

hydro -br ornate 

Valerian 

Sulphate of 

soda 

Aconite 
Digitalis 



338 



DISEASES OF THE DUCTLESS GLANDS 



Iodine 



Surgical treat- 
ment 



Partial thy- 
roidectomy 



Resection of 
the sympa- 
thetic 



cardia, however, is aconite. It should be given in intervals of 
from one to three hours and in doses of from one to three drops 
of the tincture until the desired effect is produced. Patients with 
Graves' disease may, to advantage, be kept on small doses of aco- 
nite for almost indefinite periods. Digitalis has no place in the 
treatment of this disease unless there is cardiac insufficiency. Even 
here great care must be exercised, for the constant over-action of 
the heart in this disorder frequently produces myocarditis and here 
digitalis, as has been shown elsewhere, is a dangerous drug. While 
it is possible with digitalis to reduce the number of heart beats, it 
should never be used in this disease for this purpose alone, i. e., it 
should never be given in doses large enough to appreciably slow 
the heart. 

Iodine is another remedy that is commonly used in Graves' 
disease. Just why has never become quite clear to me, unless it 
be that there is a vague idea in the heads of some that iodine has 
something to do with the thyroid. Its employment is mentioned 
merely because this drug has been very popular in the treatment of 
exophthalmic goitre. Clinically, in my experience, iodine and 
iodides almost invariably do harm in this disease, and, as a rule, 
produce an exacerbation of all the symptoms. 

The surgical treatment of Graves' disease consists either in the 
extirpation of the gland, or of portions of the gland, ligation of the 
thyroid arteries or resection of the sympathetic or its ganglia. The 
results obtained from thyroidectomy in true exophthalmic goitre 
are only partially satisfactory even in the most expert hands. The 
operation has not infrequently been followed by very disagreeable 
consequences, notably about the heart, and occasionally death. The 
operation, however, may become necessary as an emergency meas- 
ure if the thyroid enlargement is so considerable that dangerous 
symptoms of pressure upon the trachea, the esophagus or adjacent 
blood vessels or nerves occurs and the patient's life becomes en- 
dangered from this source. 

Resection of the sympathetic is an operation that theoretically 
is well founded. I have never had an opportunity to follow a case 
of Graves' disease before and after resection of the sympathetic or 
its ganglia in the neck. A critical review of the literature and of 
the various case reports fails to convince me that the operation is 
indicated, because equally good results seem to be obtainable with 
other means. The operation is certainly not without danger, as a 
number of fatal cases have been reported, and if the patients sur- 
vive the operation, disagreeable symptoms, especially about the 
psychic sphere, seem to develop and to persist for a long time. 
Judgment in regard to the advisability of this operation and of 
partial or complete thyroidectomy, as well as an expression of 



DISEASES OF THE DUCTLESS GLANDS 



339 



opinion in regard to the exact indications for surgical intervention, 
will have to be reserved until we know more about this subject. 



SIMPLE GOITRE. 



Rationale for 
the use of 
thyroid 



This disorder, especially simple parenchymatous hypertrophy 
of the thyroid, as frequently seen in juvenile individuals, often 
yields to thyroid medication. If, however, degenerative changes 
are present in the parenchyma of the gland, if the enlargement 
of the thyroid is due to vascular disturbances, as in Graves' dis- 
ease, or if it is due to hyperplasia of the interstitial tissues, or to 
tumor formation, then thyroid treatment rarely exercises any bene- 
ficial effects. 

In the hypertrophic variety of thyroid swelling in adolescents 
we must assume that the thyroid is endeavoring to meet the increas- 
ing demands of the growing organism by compensatory over- 
activity. By supplying thyroid we relieve the gland of some of 
this excessive labor, and in this way spare the organ, prevent per- 
manent functional inadequacy or degenerative changes, and thus 
enable it to regain its normal function and size. In this form 
very remarkable results are occasionally observed from the tem- 
porary administration even of small doses of thyroid or of iodothy- 
rin. The largest statistics on the subject have been gathered by 
H. G. Wells, who reported 584 cases of struma simplex treated with 
thyroid extract, of which 62 per cent, were improved. The best 
results are obtained in recent cases, so that the treatment should 
be instituted as early as possible. The remedy must be continued 
in small doses for a long time, either uninterruptedly or with short 
intermissions, otherwise recurrences are apt to appear. Here, again, 
the simultaneous administration of Fowler's solution in small 
doses is of signal benefit in preventing the disagreeable symptoms 
of thyroidism. 

It is interesting to note that very good results are also occa- Thymus 
sionally observed in simple goitre from the administration of 
thymus preparations, preferably given in tablet form, in gradual- 
ly increasing doses. 

The indications for the use of other remedies than thyroid and 
thymus, and for dietetic, hydro-therapeutic and electric means of 
treatment, do not differ materially from those described under 
Exophthalmic Goitre. 

In extreme cases that do not yield to medical means removal 
of the gland, or a portion of the thyroid, often remains the only 
resource. 



340 DISEASES OF THE DUCTLESS GLANDS 

ADDISON'S DISEASE. 

The treatment of Addison's disease, owing to our uncertain 
knowledge of its pathology, is in a very unsatisfactory state. No 
case of Addison's disease has ever been cured. The patient's 
strength must be supported during the attacks of weakness that so 
commonly supervene in this affection, preferably by rest in bed 
and the use of a nourishing diet containing an abundance of pro- 
teid foods. General tonics, notably strychnia and arsenic, may 
be administered. 

The anemia should be treated like any other anemia. The 
gastro-intestinal symptoms should be treated as described under 
Diseases of the Stomach and Intestine. Particular care should be 
taken in this disease to refrain from the administration of strong 
purges, as otherwise very intractible diarrheas may be induced. 
Hydro-therapeutic measures, electricity and transfusion have re- 
peatedly been tried without any determinable effect. 

The use of fresh suprarenal glands and of suprarenal extract 
is always indicated for, in the majority of cases of Addison's dis- 
ease, marked organic changes, frequently obliteration, of the supra- 
The use of renal glands have been discovered. The use of suprarenal prep- 

suprarenals arations has, however, never cured a case. In many instances 

marked improvement followed the administration of this remedy; 
in an equally large proportion of cases, however, one must confess 
that no appreciable effect could be discovered from its use. In 
those in which the preparation seemed to relieve, withdrawal of the 
remedy was almost invariably followed by an aggravation of the 
symptoms; which demonstrates that the suprarenal treatment has 
some virtue. Here and there in the literature is found a case re- 
port in which the condition of the patient seems to have been ren- 
dered worse by the use of suprarenal preparations, but this fact 
should not militate against their use in view of the utter inade- 
quacy of all other remedial measures. It is difficult, moreover, to 
conservatively interpret either amelioration or aggravation from 
the use of any remedy in Addison's disease, owing to the spon- 
taneous fluctuations in the condition of the patient that are so 
characteristic of this disorder. When one considers that there are 
hardly one hundred well authenticated cases of Addison's disease 
recorded in the literature; that many of them were not studied 
with accuracy ; that most of them came under observation at a very 
late stage; that finally some of the suprarenal preparations em- 
ployed were inert; then the conclusion becomes unavoidable that 
the question of suprarenal therapy in this disease can in no sense 
be considered settled. 



DISEASES OF THE DUCTLESS GLANDS 341 

When one considers further that the active principles contained 
in the suprarenal gland undergo very radical changes in the diges- 
tive tract within a short time; that the percentage of hypothetical 
active principles varies greatly in the different glands; then some 
of these indifferent results may also be understood. 

The remedy should, at all events, be given a thorough trial. 
The earlier the disease comes under observation the more apt is one 
to obtain some therapeutic results, at least symptomatically. The 
best preparation to use is the powdered extract. The dose cannot 
be specified; too much can^ however, hardly be given, as no unto- 
ward effects, excepting some irritative phenomena about the stom- 
ach or intestine, are ever observed from the administration of these 
preparations by mouth. Some authorities claim to have obtained 
better results from the use of fresh gland, given in doses of two 
or three glands (from sheep) a day. Adrenalin has been used, Adrenalin 
but the results seen from this remedy are no better, probably less 
favorable, than those obtained from the use of the dry extract or 
the fresh glands. 






CHAPTER VI. 

DISEASES OF THE URINARY APPARATUS. 

NEPHRITIS. 

The classification of nephritis, if we are to follow orthodox Prophylaxis 
standards, is highly confusing. From the anatomic, i. e., de- 
scriptive pathologic standpoint, the matter is simple enough; from 
the clinical, i. e., the diagnostic and therapeutic standpoint, the 
anatomic classification is in a large measure useless. Clinically, 
we should distinguish (1), an acute nephritis; (2), a chronic 
parenchymatous or interstitial nephritis developing either consecu- 
tively to an acute nephritis, or slowly and insidiously from the 
beginning; (3), different types of "vascular" nephritis (cardio- 
renal disease), i. e., of nephritis due to impaired circulation in the 
kidneys with resulting degenerative changes in the organ; to the 
latter category belong, e. g., the nephritis of Bright's disease, in 
the modern sense, and the nephritis of arterio-sclerosis. 

The matter is further complicated by the fact that in all 
forms of chronic nephritis cardio-vascular signs develop, sooner 
or later ; so that it is often a difficult matter to determine whether 
the changes about the heart and arteries are the primary event 
that produces the nephritis, or whether the nephritis causes reten- 
tion of excrementitious bodies that poison the heart and arteries, 
or, finally, whether the same primary cause simultaneously affects 
both the cardio-vascular apparatus and the kidneys. From a 
therapeutic point of view it is very important to decide this mat- 
ter, and I intend in the following discussion of chronic nephritis 
to consider as belonging to the second category those forms 
in which the cardio-vascular signs appear after the nephritis, and 
to the third category ("vascular nephritis") those forms that are 
either directly preceded by, and traceable to, cardio-vascular 
disease or that develop simultaneously with cardiac and arterial 
disturbances. 

As far as the further differentiation of nephritis into the 
parenchymatous and the interstitial forms is concerned, I con- 
sider that unimportant in the therapeutic sense, for there is 



344 



DISEASES OF THE URINARY APPARATUS 



never a parenchymatous inflammation without some interstitial 
changes, nor vice versa. The involvement of the renal paren- 
chyma or of the interstitial tissues of the kidneys will depend 
altogether upon the kind, the virulence, the selective affinities of 
the various toxic and infectious agents that produce the 
nephritis, upon the length of time during which they irritate the 
kidneys and upon the path by which they reach them. Generally 
speaking the more chronic the nephritis the more marked the 
interstitial changes. In the vascular type, too, interstitial changes 
usually predominate. 



ACUTE NEPHRITIS. 



Classification 



Abundant wa- 
ter drinking 



Restriction of 
liquids 



To the kidneys is relegated the chief disintoxicating func- 
tion of the organism, hence they are particularly susceptible to 
injury by any toxic or infectious material that may gain en- 
trance to the circulation. Recognizing this fact it is occasionally 
possible, in certain infectious diseases, to prevent the development 
of nephritis as a complication, first, by giving such abundant 
quantities of fluid early in the disease that whatever toxins are 
carried through the renal filter are thoroughly diluted and hence 
not so apt to irritate and inflame the renal epithelia in transit; 
second, by avoiding the administration of remedies that can irri- 
tate the kidneys.* In some diseases, moreover, energetic causal 
treatment instituted early may save the kidneys; thus in malaria 
an active quinine treatment may often prevent the development of 
nephritis, and in syphilis, paradoxical as it may sound, an ener- 
getic mercury treatment may also prevent renal complications, 
notwithstanding the fact that mercury in itself is capable of irri- 
tating the kidneys. 

The administration of abundant quantities of water in acute 
infectious diseases is a useful procedure, only, however, while the 
renal filter is still permeable for water and before pronounced 
nephritic changes have appeared. When nephritis has once set 
in the administration of water should be reduced considerably, at 
least during the period of acute inflammation, and the adminis- 
tration of large quantities of water should not be resumed until 
the nephritic process is in course of healing. One should be 
guided, in this matter, largely by the function of the kidneys; 
when they stop excreting abundantly it is bad practice to try to 
force them to eliminate water, and one should wait with abundant 
water-drinking until the kidneys indicate by increased diuresis 



♦Salicylic acid preparations, chlorate of potash, most of the 
balsams, tar, turpentine, cantharides, etc. 



DISEASES OF THE URINARY APPARATUS 345 

that they are again capable of excreting water. Of this more be- 
low when discussing the diet, in acute nephritis. 

The diet, in acute nephritis, should, during the stage of in- Diet 
nammation, be scanty and bland. The principle of sparing the 
kidneys by relieving them of the task of excreting much solid 
excrement is the prime indication and should be carefully ob- 
served. In certain infectious diseases of short duration it is not 
a bad plan to withhold food altogether for a period of two or three 
days, allowing the patient only enough water to allay the thirst 
and to compensate for the loss of water through the breath and 
the sweat glands. This treatment is heroic, but, especially in starvation 
children, the results are so gratifying as to warrant its employ- 
ment. The fact that the patients are forced to consume their 
own tissues and are inadequately nourished by this procedure need 
not militate against the starvation treatment, inasmuch as under- 
nutrition, lasting for two or three days only, can do no 
harm. In chronic forms of nephritis the starvation plan, or even 
continuous under-feeding, with the object of sparing the kidneys, 
is, of course, never permissible, as will be shown at length 
later on. 

If one is justified in assuming that the acute nephritic inflam- Milk 
mation will last longer than two or three days, or if the renal 
complication does not rapidly yield to complete withdrawal of 
food, then milk is the best nutrient. It should constitute, in 
acute nephritis, the only food until the nephritic process has 
entered into the sub-acute stage. Occasionally a patient cannot 
bear milk, either on account of an aversion to it, or on account 
of inability to digest it; in such cases the administration of small 
quantities of milk, in tablespoonful doses, given ice cold and 
possibly with the addition of a little lime water or some flavoring 
extract, will often render its administration possible. If there Buttermilk 
is complete intolerance or aversion to milk, then buttermilk or Kumyss 
kefir or kumyss can frequently be borne, and while these bever- Kefir 
ages do not possess the nutritive value of an equivalent of milk, 
still they serve a very useful purpose. The quantity of milk 
must vary according to the individual case, but more than one 
litre should rarely be given during the twenty-four hours. In 
order to increase the nutritive value of the milk cream may 
be added; a tumbler full of milk-cream mixture, containing four 
parts of milk and one part of cream, with one tablespoonful of 
lime water, administered every two or three hours, suffices to ade- 
quately nourish the patient, and at the same time to 
spare the kidneys during the acute and sub-acute stages of the 
nephritis. 



346 



DISEASES OE THE URINARY APPARATUS 



Diet during 
the stage of 
healing 



Meat 



Rest 



Position in bed 



Catching cold 



Clothing dur- 
ing conva- 
lescence 



Symptomatic 
treatment 



During the stage of healing it becomes necessary to nourish 
the patient more generously. This can be done with safety by al- 
lowing soups made of oatmeal, rice and barley, a little bread or 
zwieback, some fresh fruit and boiled vegetables. Meat extracts 
or bouillons exercise a beneficial and stimulating effect upon the 
appetite and the gastric digestion without, at the same time, con- 
taining elements that markedly irritate the kidneys; nor do they, 
it is true, contain any elements that are particularly nourishing, 
hence, they can hardly be considered a food, as their caloric value 
is very small. Later the ordinary mixed diet should be 
resumed, always under careful supervision of the urine, in 
order to control the effect of a liberal diet upon the healing of the 
nephritic process. 

Meat should preferably be withheld until the healing is well 
advanced. I do not think that the kind of meat makes much 
difference, although possibly, in honor of an old fashioned prej- 
udice, light meats may be given the preference over dark meats. 

As soon as symptoms of acute nephritis make their appear- 
ance the patient should be put to bed and kept absolutely quiet 
until the inflammation of the kidneys subsides. As a rule ne- 
phritic cases lie on their back, but it is a very good plan, if 
they can comfortably do so, to have them lie on the abdomen, 
at least during part of the day. They should at all events fre- 
quently change their position in bed, for in this way, hypostatic 
congestion of the kidneys is prevented, and, in many cases, the 
pain in the lumbar region is markedly reduced. The patient 
should remain in bed until the albumin has disappeared from 
the urine. Even after this stage has been reached, the patient 
should at first arise for a short time only each day, and never 
within an hour or two after a meal. The urine should be carefully 
controlled daily and the patient ordered back to bed as soon as 
albumin reappears upon exertion. Unless this precaution is taken 
chronic nephritis is very apt to develop. 

Nephritics or individuals who have just recovered from acute 
nephritis are very liable to catch cold. Possibly there is in such 
cases a lowering of the tone of the vaso-motor centers as 
a result of the renal intoxication. Particular precautions should 
be therefore taken to prevent taking cold, according to the 
principles discussed otherwhere. Convalescents from acute ne- 
phritis should at all events always wear a flannel binder covering 
the kidney region for many months after recovery, and should 
be warned particularly against exposing themselves to wet or 
cold. 

The symptomatic treatment of acute nephritis includes among 
other things the relief of the pain in the kidney region that is 



DISEASES OF THE URINARY APPARATUS 347 

often quite distressing. Remembering always that no drug should 
be given in nephritis that can irritate the kidneys, care should be 
taken in selecting proper counter-irritants to be applied to the 
lumbar region. Thus cantharidal ointments or plasters, or mus- Counter-irri- 
tard poultices and plasters, that are very useful as revulsives, reg i on 
should never be used in acute nephritis. Cupping or the applica- 
tion of leeches is, however, a very useful treatment for the re- 
lief of renal pain. The galvano-cautery may be employed to 
advantage, especially when applied over Petit's triangle,* for 
the veins in this area anastomose with the veins of the renal cap- 
sule so that congestion within and around the kidneys can be 
effectively relieved by counter-irritation over this particular point. 
Cups, leeches or the cautery may be advantageously applied 
throughout the whole duration of the acute stage, for they can 
never do any harm and frequently seem to exercise a very bene- 
ficial effect, especially upon the pain and the reflex nerv- 
ous symptoms of renal origin, viz., the headache, nervousness and 
vomiting. 

Different drugs have been recommended from time to time Drugs to re- 
for reducing the albuminuria. Aside from the fact that the ex- jj™ e albumin- 
cretion of albumin is a symptom of subordinate importance as 
far as any effect upon the nutrition of the patient is concerned, 
so that it hardly calls for special treatment, the various rem- 
dies used cannot be considered efficacious even to fulfill the pur- 
pose for which they are intended. They are mentioned merely 
on account of their historical interest. Thus tannin and tannal- 
bin, methyl violet and methylene blue, strontium bromide and 
ichthyol and sodium benzoate, fuchsin and nitric acid all have 
their advocates, but none of them, in my experience, is of any 
benefit whatsoever in the treatment of acute nephritis. 

In case there is very much hematuria ergot may be given, al- Hematuria 
though the loss of blood is usually too insignificant to warrant 
special consideration. Ergot should be given in the form of 
the fluid extract, 15 m. to 1 dr. (1.0 to 4.0) or the infusion 1 to 
2 oz. (16 to 32 cc). 

The suppression of urine occasionally calls for treatment al- Anuria 
though as a rule it is best to allow Nature to take its course and 
to wait a few days without active interference until the kidneys 
spontaneously resume their function. To force the kidneys to 
pass water always means to irritate them; there is, more- 
over, no tangible evidence to show that the promotion of 
diuresis by drugs really promotes the elimination at the same 

♦Petit's triangle is the area bounded by the crest of the ilium 
below, the latissimus dorsi and the external abdominal oblique on 
each side. 



348 



DISEASES OE THE URINARY APPARATUS 



Vicarious 
elimination 



Milk as a 
diuretic 



Alkalies the 
only legitimate 
direutic in 
acute nephritis 



Diuretics in 

dangerous 

edemas 



Heart tonics 



Digitalis and 
caffein 

Acetate of 
potash 

Calomel 



time of large quantities of urinary solids, so that the slight ad- 
vantages accruing from forced diuresis are, as a rule, more than 
counter-balanced by the damage inflicted upon the kidneys by the 
diuretics employed. 

The elimination of retained urinary bodies should, therefore, 
be promoted not by crowding them through the kidneys but 
by favoring their vicarious elimination through the bowel, and, 
so far as that is possible, through the sweat glands. It is more 
important, as shown above, to regulate the diet in such a way 
that only small amounts of excrementitious bodies have to clamor 
for elimination through the closed renal filter, than to feed inju- 
diciously and try to force urinary bodies through a barrier that 
Nature has closed for the time being. It is well to remember that 
the chief task, in the treatment of nephritis, as of any other acute 
disorder, is to imitate Nature and to enforce her methods, viz., to 
spare the diseased organ and to keep it at rest in order to enable it, 
as quickly as possible, to resume its normal function. 

Milk itself stimulates diuresis in a perfectly physiological 
manner, and if the patient with nephritis fails to pass a sufficient 
quantity of urine on an abundant milk diet, then this, in itself, is 
evidence that the kidneys cannot react to the stimulus even of 
mild diuretics. The reduction of the flow of urine, on a milk diet, 
is, therefore, prognostically, a bad sign and should induce us to be 
particularly careful not to irritate the inflamed kidneys still further 
by the use of strong diuretics. 

The only legitimate diuretics, in the sub-acute stage of nephritis, 
are alkalies and alkaline mineral waters, preferably given in com- 
bination with milk. They act either by their effect upon the osmotic 
pressure of the blood in the kidneys and hence favor diuresis by 
their physical properties, or they produce, as some authors claim, 
a reduction in the renal congestion, without in any way irritating 
the diseased renal cells. 

If the patient is suffering from severe edemas and an accumu- 
lation of fluid in the serous cavities large enough to endanger life 
mechanically by pressure, and if sweating and active catharsis do 
not relieve these dropsical swellings, then recourse must occasionally 
be had, as an emergency measure, to strong diuretics. As the heart 
in the great majority of these cases is affected (so-called nephritic 
edemas generally being cardiac edemas), heart tonics should always 
be administered in combination with a duretic. 

No combination is more useful in such cases than the one 
described in discussing cardiac dropsy, namely, digitalis with 
caffein. The acetate of potash is commonly used; it acts as any 
other alkali for it reaches the kidneys in the form of potassium 
carbonate. Calomel, too, may be used for its diuretic properties 



DISEASES OF THE URINARY APPARATUS 349 

in these extreme cases, and should be given as described under 
cardiac dropsies. Diuretic teas are very popular with the laity; it Diuretic teas 
i9 doubtful whether the herbs that are used in their preparation 
possess very strong diuretic powers ; the ingestion of large quantities 
of hot water, however, without doubt stimulates the function of the 
sweat glands and possibly also of the kidneys, while the herb infu- 
sion can do no harm. One of the best of these teas is composed of 
equal parts of fol. uva ursi and herba hernearia glabra; a cup of 
tea made with half a teaspoonful of this mixture of the two dried 
herbs and sweetened with sugar should be given every two hours; 
especially in sub-acute nephritis a profuse diuresis can usually be 
stimulated by this mixture while the sweat glands also become very 
active. 

Most cases of acute nephritis are benefited by the use of luke- Hydrotherapy 
warm baths given for fifteen minutes at a time and accompanied by 
friction of the surfaces of the body. Such a bath should be given 
once a day. The effect of this practice upon the blood pressure 
becomes manifest, as a rule, by increased diuresis and sweating. If 
it is desired to produce profuse sweating, then hot baths of 35° Sweating by 
to 40° C, should be given and the patient afterwards wrapped in s 

warm blankets. If a profuse sweat is produced in this way, the 
patient should, at the same time, be given abundant quantities of 
water to drink, as otherwise concentration of the body fluids may 
be brought about, hence their toxicity be increased and the danger 
of uremia enhanced. 

One might ask what benefit could accrue from sweating on the Sweating and 
one hand and giving abundant water on the other, especially if, as terdrinkin?" 
claimed above, little poisonous material is eliminated by the sweat 
glands. The main effect produced is an active circulation of the 
lymph which acts beneficially by increasing metabolism, by prevent- 
ing stagnation and accumulation of toxic material in certain por- 
tions of the body, where they might do particular harm, especially 
in certain areas of the nervous system. 

One of the most convenient methods for producing diaphoresis Sweating by 
is by means of the hot air bath, as described under Cardiac Dropsy, air 

or by the use of large Priesnitz compresses covering the whole body. 
In promoting sweating by the Priesnitz method, a sheet is wrung Sweating by 
out of hot water, wrapped around the patient and covered with presses* 1 " 
two or three woolen blankets. In order to forestall dyspnea and 
reactive cerebral hyperemia, the patient should be placed in a semi- 
recumbent position and the head kept cool with cold cloths or an 
ice bag. As the patients usually soon complain of thirst they should 
be given plenty of cold water to drink during the sweating. 

Pilocarpine, by subcutaneous injection, also produces a profuse Sweating by 
sweat, but this drug should only be used if the heart is altogether pi ocarpine 



350 



DISEASES OF THE URINARY APPARATUS 



Catharsis 



Heart tonics 



intact. I consider pilocarpine dangerous in heart disease and gen- 
erally superfluous in nephritis. 

Mild catharsis may to advantage be promoted. Great care 
should, however, be taken not to administer drugs that can irritate 
the bowel, for upon the bowel chiefly is thrown the task of vicari- 
ously ridding the system of excrementitious bodies that the kidneys 
are for the time being unable to excrete. Any derangement of the 
bowel function, therefore, should be most strenuously avoided; the 
same applies to the liver, for it, too, assumes a disintoxicating and 
a vicariously eliminating function in nephritis. For these reasons 
calomel and all drastic purges should be used only as an emergency 
measure in extreme cases. To evacuate the bowel castor oil or 
cascara, of the extract two to eight grains (0.12 to 0.5 gm.), of 
the fluid extract ten to fifteen minims (0.6 to 1 cc), may be safely 
given. Saline purgatives are to be avoided, for most salts either 
irritate the kidneys or are eliminated with difficulty by the kidneys 
when they are diseased. 

That it may occasionally become necessary to supply digitalis 
as soon as the heart begins to flag in acute nephritis, is self-evident. 
It is not good practice, however, to give digitalis in the beginning 
for the sake of its diuretic effect, because, in acute nephritis, a great 
strain is always thrown upon the heart sooner or later and it is 
decidedly dangerous to stimulate it with heart tonics before there 
is an urgent call for their employment. 



CHRONIC NEPHRITIS AND BRIGHT'S DISEASE. 



Cardio-renal 
disease 



The newer con- 
ception of 
Bright's dis- 
ease 



In addition to those forms of chronic nephritis that develop 
consecutively to acute nephritis, we have a variety of forms in 
which the involvement of the kidneys is merely one symptom of a 
general toxemia, and in which the disorder about the heart and 
arteries dominates the picture. In some forms the disease seems 
to affect the kidneys first, and later the heart and arteries ; in others 
the toxemia seems to involve simultaneously the heart and arteries. 
The latter variety, according to our newer idea, is true Bright's 
disease. It is unfortunate that the name Bright's disease is retained 
at all in our medical nomenclature, for what we understand by this 
term, and what Eichard Bright originally described, are two very 
different things. It is still more unfortunate that the terms Bright's 
disease and chronic nephritis are so commonly employed synony- 
mously; for Bright's disease, in the modern sense, is a systemic 
disorder that usually produces nephritis, but does not invariably 
do so, whereas chronic nephritis, while often due to Bright's disease, 
may also be due to a great many other causes. 



DISEASES OF THE URINARY APPARATUS 351 

In B right's disease, the determining feature is high arterial 
tension, with resulting cardio-vascular changes and nutritional 
disorders in various parts of the body, and, particularly, in those 
organs that are supplied by end-arteries, viz., the kidneys, the 
retina, and the brain. The treatment of this so-called vascular type 
of nephritis is therefore practically synonymous with the treatment 
of the cardio-vascular apparatus ; for cardio-vascular disorders gener- 
ally usher in these forms of nephritis or appear soon after nephritic 
signs become apparent; and cardio-vascular complications generally 
produce the death of these patients. Cases of this type of nephritis 
should be treated, therefore, more as heart cases than as kidney 
cases, and for this reason the rules of treatment that have been 
laid down in the Chapter on Heart Diseases, particularly in the 
paragraphs on the treatment of valvular diseases of the heart in 
the stage of compensation, apply, broadly speaking, to this type of 
nephritis. 

Causal treatment of any variety of chronic nephritis must con- Causal treat- 
cern itself primarily with combating or preventing the toxemia that, 
in all probability, produces both the cardio-vascular changes and the 
nephritis. The character of this toxemia is still obscure. The 
preponderance of clinical evidence, however, points to a disordered 
gastro-intestinal tract and liver, on the one hand, and to metabolic 
derangement on the other, as the sources of the poisons. Treatment 
should, therefore, in many cases be directed towards correcting any 
digestive or hepatic disorders that may be present. The obscure 
metabolic perversions that sometimes underlie the disease unfortu- 
nately offer nothing very tangible to attack. 

A deranged bowel function leads to the abnormal disassimilation **owe * origin 
of albumins, chiefly because putrefactive bacteria gain unopposed nephritis 
sway. The toxic albuminoids and alkaloids generated in this way 
flood the liver channels, where they should normally be arrested 
or disinfected. For a while the hepatic cells can withstand the 
stream of toxic matter that circulates around and through them 
and can properly exercise their disinfecting properties; but an 
overwhelming mass of putrefactive material flooding them at one 
time, or small quantities of putrid excrement irritating them con- 
tinuously, must needs impair their function and render them inade- 
quate to protect the organism as a whole from poisoning. When 
this occurs intestinal toxins filter through into the circulation 
beyond, and there can exercise their deleterious effect on the heart, 
on the arteries, and also on those organs that chiefly supplement 
the disinfecting function of the liver by eliminating poisons, 
namely, the kidneys. 

Hepatic insufficiency produced in this way also leads to the Hepatic insuf- 
incomplete elaboration of the afore-mentioned intermediary products cie y 



352 DISEASES OE THE URINARY APPARATUS 

of metabolism that reach the liver in the general circulation as 
poisonous bases, ammonium salts, etc., and should leave the liver 
more highly oxidized as innocuous uric acid, urea, etc. When the 
liver cells are inadequate to produce this conversion, then these 
intermediary bodies are returned unchanged to the general circula- 
tion, and thus cause auto-intoxication. That some of these bodies 
can produce the cardio-vascular changes of Bright's disease, and 
some of the renal changes, was shown by me in 1901.* 

Another important result of hepatic insufficiency is perversion 
of the physical and chemical character of the bile. Instead of 
flushing the bile channels in a broad stream the bile sluggishly oozes 
through the hepatic capillaries. The thick and viscid character of 
the bile favors diapedesis of poisonous bile ingredients from the bile 
channels into the blood capillaries and besides produces clogging 
of liver channels, with pressure on the hepatic cells and on the 
afferent blood capillaries that nourish them ; as a result the function 
of the liver cells is still further impaired and self-intoxication is 
favored. 
Intestinal an- Finally the absence of the proper quantity of normal bile from 

scpsig ^ e j n ^ es ^ ne deprives the organism of its most important antiseptic 

secretion, so that intestinal putrefaction increases and a vicious 
circle is in this way closed. 

Causal treatment of Bright's disease must concern itself, there- 
fore, in the first place, with the prevention of intestinal putrefac- 
tion. Sterilization of the human intestine with its thirty feet, more 
or less, of warm, moist culture medium is manifestly impossible: 
nor is it desirable, for many of the micro-organisms that normally 
abound in the bowel aid the enteric ferments in the disassimilation 
of the food and produce certain physical changes in the bowel 
contents that favor the act of defecation. 

The human intestine is practically sterile at birth ; later bacteria 
appear in the bowel contents, some of them pathogenic. Against 
the latter the organism normally protects itself by very efficient 
means ; when these measures become inadequate, artificial intestinal 
antisepsis is called for. The object of intestinal antisepsis, so-called, 
is not, therefore, to free the bowel from bacteria, but to prevent the 
pullulation of certain pathogenic species and to destroy their 
poisons. Kemedies employed to this end may become operative in 
two ways: they may either act chemically by direct contact, or 
they may act physiologically by stimulating the natural defenses of 
the organism to greater activity. 



*Croftan — "The Role of the Alloxuric Bases in the Production of the 
Cardio-vascular Changes of Nephritis." Am. Jour. Med. Sciences, Feb- 
ruary, 1901. 



DISEASES OF THE URINARY APPARATUS 353 

Most of the drugs employed as intestinal antiseptics fulfill both 
indications, inasmuch as they possess not only germicidal properties, 
but also act as hepatic stimulants. As the liver cells possess the 
power of arresting and of disinfecting many bowel poisons, and as 
the bile is a germicide, any remedy that causes increased activity of 
the hepatic cells and, by inference, acts as a cholagogue may be 
considered an intestinal antiseptic of the second variety. 

Chief among the remedies recommended as intestinal antiseptics Metallic salts 
are certain metallic salts, the bile acids and certain organic peroxids. Bile a ^ds 
It is necessary, of course, that these remedies when given in doses xj§es 1C PCr " 
sufficiently large to check intestinal putrefaction should be non- 
irritating and non-poisonous. For this reason I prefer the sulpho- Sulphocarbo- 
carbolate of zinc to other metallic salts (mercury, lead, silver, cop- „ ,. . 

per), and sodium glycocholate to the free bile acids. A variety of cholate 
organic peroxids under various trade names are on the market and 
I consider them useful. 

Intestinal putrefaction may be considered checked when certain Urinary _ and 
bodies that we know to be formed from the putrefactive disintegra- dwice^" intes- 
tion of albumin disappear from the feces and from the urine (abnor- tinal putre- 
mal degradation products of the fats and carbohydrates play a 
subordinate role in auto-intoxication). Chief among these are a 
variety of aromatic sulphur compounds and a complex group of 
substances that also contain the aromatic radicals that are split off 
from putrefying albumin (compound glycuronates and compound 
glycocols).* 

For clinical purposes it is sufficient to study the sulphids of the 
feces and the aromatic sulphates (with indican as their prototype) 
of the urine. 

The intestinal antiseptics should be given in small doses (sul- Dose and ad- 
phocarbolate of zinc, one-half grain (0.03 gm.) ; sodium glycocho- f intestinal 
late, one grain (0.06 gm) ; the organic peroxids, one grain (0.06 antiseptics 
gm.), at frequent intervals, together with about twenty grains (1.2 
gm.) of bismuth subnitrate in the twenty-four hours. The latter 
is given merely as an indicator of the presence or absence of sulphids 
(sulphureted hydrogen or its salts) from the feces. H 2 S or its 
alkali salts form black bismuth sulphid, and when the intestinal 
antiseptic is given in sufficient quantity to check the putrefaction of 
albumin, then no bismuth sulphid is formed and the stools are not 
colored black. 

It will be found in most cases that when the stools retain a light 
color, despite the administration of bismuth, the indican of the 
urine and the other aromatic urinary ingredients will also disappear 
or become greatly reduced. 



'See Croftan: Clinical Urinology, Chapter VII (Cleveland Press). 



354 



DISEASES OF THE URINARY APPARATUS 



Diet 



The quantity 
of food 



The dangers of 
an exclusive 
milk diet 



Deficit of iron 

in milk 



The proper dose, then, of the above-named intestinal antiseptics 
is enough to prevent blackening of the stools after the ingestion 
of bismuth subnitrate and enough to cause the disappearance from 
the urine of aromatic bodies. 

The Diet in Chronic Nephritis. In feeding patients suffering 
from chronic nephritis three conditions must be fulfilled. First, 
the diefc must contain qualitatively and quantitatively all that is 
needed to maintain general nutrition (nutritive equilibrium). Sec- 
ond, the diet must contain as little as possible of materials that in 
their ultimate passage through the kidneys can irritate the renal 
epithelia or the glomeruli. Third, the diet, while sparing the 
kidney function, must not overtax or otherwise injure the function 
of the digestive or circulatory organs. One may say, in a broad 
sense, that the daily amount of food, expressed in caloric values, 
should be inversely proportionate to the presumable duration of the 
nephritis. In acute forms of nephritis, as we have seen, under- 
feeding or even starvation of the patient not only is permissible, 
but is good practice ; for the smaller the amount of excrementitious 
bodies the kidneys are forced to eliminate the more they are spared 
and the more rapidly can they resume their normal function. The 
more chronic the nephritis, however, the more nutritive should be 
the diet, so that patients suffering from this disease should receive 
daily the full caloric value in their diet that is required to maintain 
nutritive equilibrium. 

For many years it has been fashionable to feed cases of chronic 
nephritis upon an exclusive milk diet. This method of feeding we 
owe chiefly to the French school of clinicians and to numerous imi- 
tators that this school has educated, including the laity. That milk 
is a useful article of diet in the management of nephritis, probably 
the most useful article we possess, no one will gainsay. That a milk 
diet should be given persistently and should constitute a large pro- 
portion of the food to be administered to cases of chronic nephritis 
is also conceded. An exclusive milk diet, however, is directly harm- 
ful and dangerous in chronic nephritis, if carried out for too long 
a time. 

Milk alone cannot maintain the general nutrition for any length 
of time unless enormous quantities are given. There is always, in 
the first place, a deficiency of one all-important element, viz., iron. 
In regard to this deficiency of iron, one might argue that, as milk 
can nourish infants for a year or longer, the amount of iron in the 
milk should be sufficient to fulfill all the demands of the organism. 
As a matter of fact, however, it has been demonstrated that milk 
while it contains exactly the same proportion of calcium, mag- 
nesium, potassium, phosphorus, etc., as the ash of the new born 
animal of the species from which it is derived, contains six times 



DISEASES OE THE URINARY APPARATUS 355 

less iron. This anomaly is explained by the fact that the iron 
content of young suckling creatures decreases with the age of the 
animal and reaches its minimum at the time when iron-containing 
food is first eaten. The young animal, therefore, brings a surplus 
of iron into the world and is independent of the milk for his supply ; 
but this does not apply to adult individuals. Here then, in the 
first place, is a qualitative deficit that must by all means be remedied 
if an exclusive milk diet is to be given, or even if the patient is 
fed on a diet consisting largely of milk. This is best done by 
adding either chloride of iron solution to the milk or by diluting 
it with iron-containing mineral waters. It is not impossible that 
the lack of iron in the milk contributes in part to the anemia that 
is so common in patients with chronic nephritis who become martyrs 
of an exclusive milk regime. 

The second most important postulate in the proper feeding of Excess of nitro- 
chronic nephritics, viz., to spare the kidneys, is also violated if too products W3S C 
much milk is given; for it is a well known fact that albuminous 
foods by leading to the formation of large quantities of nitrog- 
enous end-products, chiefly urea, throw an excessive task upon the 
kidneys; for urea and its congeners are eliminated with difficulty 
when the kidneys are diseased, and must be considered as true 
irritants of the renal epithelia. It is for this reason that we reduce 
the albumens in the diet of chronic nephritis ; but if we give enough 
milk to adequately nourish these subjects then we also give an excess 
of albumen. A normal adult requires between two and three 
thousand calories to maintain full nutrition. As one litre of milk 
has a total caloric value of only about seven hundred, it is clear that 
from three to four litres of cow's milk would be required per diem 
to meet the nutritional requirements of the subject. Such amounts 
of milk contain from one hundred and twenty to one hundred and 
fifty grammes of proteids, whereas the normal average quantity 
required by a healthy adult does not exceed eighty grammes per 
diem; in fact, recent investigations seem to show that adequate 
nutrition can very well be maintained on very much less albumen. 
This is particularly the case among individuals whose vitality is 
low and who, as will be shown presently, should lead a quiet life 
with the minimum of physical exercise. 

Finally, if the patient is fed upon milk alone and if enough Excess of 
milk is given to adequately nourish him, then too much water by 
far is forced through the cardio-vaseular apparatus and the kidneys. 
The danger of stimulating diuresis by abundant water-drinking in 
acute nephritis has already been discussed, and attention has been 
called to the danger of trying to forcibly overcome the resistance 
that the diseased kidneys offer to the passage of water. In sub-acute 
forms of nephritis and in those cases that are on the border line 



water 



356 



DISEASES OF THE URINARY APPARATUS 



Drinking days 



between sub-acute and chronic nephritis, the intake of water can 
be increased; the object being to flush out the kidneys and to rid 
the kidney canals of accumulated debris. This is a useful practice, 
because by so doing mechanical obstacles to the flow of urine are 
removed, and the work of the kidneys is thereby somewhat reduced. 
If this purpose is to be accomplished, however, it is always better 
to restrict the liquids for a time and then to institute so-called 
drinking days, during which very abundant quantities of water are 
ingested. If this is done the renal canals are flushed and at the 
same time accumulated waste products are washed from the blood 
through the kidneys and out of the body. Abundant water-drink- 
ing, instituted in this way possibly once or twice a month can do 
no serious damage, whereas abundant water- drinking continuously 
Mineral waters practised undoubtedly injures the gastro-intestinal function, the 
cardio-vascular apparatus and the kidneys. A warning may inci- 
dentally, therefore, be uttered in this place against the indiscrim- 
inate use of the many mineral waters that are broadly advertised 
for the cure of kidney diseases. 

In the Chapter on Acute Nephritis, the statement was made 
that the water intake should be largely governed by the water 
output. In very chronic forms of nephritis the principle can hardly 
apply for, especially in the interstitial variety of the disease, large 
quantities of water are continuously eliminated containing a very 
small amount of solids in solution. Here, it is an easy matter to 
produce very copious diuresis by copious water-drinking, but noth- 
ing is gained by this and much damage can be done to the heart 
and arteries which are particularly affected in the latter form of 
nephritis. 

One other objection to the indiscriminate use of an exclusive 
milk diet may be formulated. It is a well known fact that phos- 
phates are excreted with difficulty when the kidneys are diseased. 
Milk is very rich in phosphates, and in a healthy individual the 
urinary phosphorus excretion is greatly increased on an exclusive 
milk diet. If the kidneys are to be spared, therefore, the urinary 
phosphate excretion should be reduced and not increased, as is done 
by feeding milk exclusively. The addition of lime salts to the milk 
can somewhat obviate this difficulty, so that in nephritis, lime water 
should always be added to the milk ; in this way, calcium phosphate 
is formed and this salt is absorbed with great difficulty from the 
intestine; consequently the bulk of the phosphates is excreted in 
the feces as calcium phosphate and is not at all absorbed into the 
circulation nor consequently eliminated in the urine. Again, an 
excess of calcium in the milk leads to the formation of chloride of 
calcium in the stomach, which is absorbed and combines in part 
with the circulating phosphates, and the latter, it is well known, 



Excess of 
phosphates 



Addition of 
lime water to 
milk 



DISEASES OF THE URINARY APPARATUS 357 

are always excreted, presumably through the bile ducts, into the 
bowel and not through the kidneys into the urine. 

There are still other objections to the exclusive milk diet that Disgust and 
may be briefly formulated as follows : Aside from the fact that t ° t s e s £ TO m^ex- 
feeding with milk alone, for a long time, becomes thoroughly dis- elusive milk 
tasteful and even disgusting to the patients, and that consequently 
the appetite is lost, and the normal psychic stimulus necessary to 
perfect digestion is perverted, the ingestion of large amounts of 
water mechanically does injury to the stomach and intestine; for 
the stomach becomes dilated and the gastro-intestinal secretion 
constantly diluted. This, of necessity, impairs the digestive powers Gastric dila- 
of the individual and may lead to a variety of chronic digestive tatlon 
disorders that, as shown above, should be strenuously avoided in 
chronic nephritis. 

All these objections just formulated apply only to the use of 
excessive quantities of milk in nephritis. If certain precautions are 
observed in regard to restricting the ingestion of milk to sensible 
limits, and if the deficit of iron is remedied by the addition of an 
iron preparation, and if the excess of phosphates is neutralized by 
the addition of lime water, milk constitutes a valuable food. 
Broadly speaking, a case of chronic nephritis should receive from How to feed 
one to one and a half litres of milk a day; never any more and mi 
preferably less. The milk should be given in divided doses, at 
frequent intervals, by choice in the form of a milk-cream mixture, 
consisting of four-fifths milk, one-fifth cream and two teaspoonfuls 
of lime water per tumbler full (nine ounces). 

Inasmuch as the function of the liver is frequently perverted in Pancreatin and 
chronic nephritis, and the character of the intestinal secretion, 
especially in its upper portions, is consequently changed, it is very 
useful to give after each ration of milk and cream, a capsule con- 
taining pancreatin and soda, to which may be added with advantage 
the bile acid salts. A gelatine capsule containing the following in- 
gredients may therefore be given four or five times a day : 

Pancreas powder, 2 grains (0.12 gm.) 

Sodium bicarbonate, 1 grain (0.06 gm.) 

Sodium glycocholate, y 2 grain (0.03 gm.) 

M. Sig. : One 3 or 4 times daily. 

As one to one and a half litres of milk contain only about 600 
to 900 calories, this amount of food is not adequate to maintain 
nutrition, consequently it is necessary to make up the caloric deficit 
by the addition of sufficient proteids, carbohydrates and fats to 
meet the caloric requirements of the individual. The rules that 
should govern the arrangement of the diet, as far as the calculation 



soda 



358 



DISEASES OF THE URINARY APPARATUS 



The kind of 
food and its 
mode of prep- 
aration 



Meats 



Sea foods 



Light and 
dark meats 



Spices and 
condiments 

Eggs 



of the caloric values are concerned, have been discussed fully in the 
Chapter on Diseases of Metabolism. 

In selecting the kind of albuminous, starchy and fat food to 
be administered and deciding upon its mode of preparation, the 
following principles should be observed: 

Albumen may be administered in the form of meats, eggs or 
vegetable albumens. Certain meats should be excluded altogether 
from the diet, chiefly those that contain extractives and toxic prin- 
ciples. To the former class belong all raw, rare, smoked, cured and 
corned meats, for they still contain the extractives. Soups, bouil- 
lons and meat extracts, as well as most gravies, contain the ex- 
tractives in solution and should be strictly eliminated from the diet 
of a chronic nephritic. Internal organs, like liver, spleen, kidney, 
brain, pancreas contain very abundant nuclein, and as nuclein in 
process of digestion is split up into the purin bodies, a group of 
substances that are distinctly toxic and can both irritate the kidneys 
and the cardio-vascular apparatus, these articles, too, should be 
excluded. In addition, game, which usually contain ptomaines, 
especially if it has hung for some time and has "hautgout," is 
dangerous. Veal is said to be rich in toxic bodies and frequently 
produces acute digestive disorders, even in well subjects; it ought 
best, therefore, to be eliminated from the diet. Sea foods of all 
kinds should be absolutely fresh, and it would be a sensible rule to 
forbid subjects living far from the seaboard to eat any salt water 
fish or crustaceans. To the category of forbidden articles also 
belongs caviar, for it contains a very large amount of nitrogen and 
an abundance of nuclein, consequently purin bases, and generally 
some ptomaines. 

There has been much discussion in the literature of recent years 
in regard to the use of light and dark meats. However convincing 
certain purely scientific researches may be that are intended to 
show that there is no difference between light and dark meats, I 
have never been able to convince myself that it is quite safe to 
depart from the old empiric rule to reduce the ingestion of dark 
and red in favor of light meats in nephritis. 

All spices and condiments should be forbidden, for they unques- 
tionably irritate the kidneys. 

Eggs were, for a long time, tabooed in nephritis ; it seems estab- 
lished that raw eggs increase the albuminuria in certain forms of 
the disease; in view of the fact, moreover, that, especially in all 
large cities, eggs are generally of the cold-storage variety, and there 
is consequently always danger of their containing ptomaines, they 
should be eaten sparingly. There is no objection, however, to the 
use of two or four fresh eggs a day. 



DISEASES OF THE URINARY APPARATUS 359 

Some care should be exercised in the selection of vegetables, Vegetables to 
thus all vegetables that contain irritating oils or other pungent e aVQ1 e 
principles, like radishes, asparagus and garlic, onions, celery should 
be excluded from the diet. Mushrooms, too, should not be per- 
mitted ; for, in the first place, they contain a very la "ge percentage 
of nitrogen for their bulk ; and in the second place, as is well known, 
frequently contain poisonous alkaloids, which, even in small quanti- 
ties, would be particularly dangerous in nephritis, because their 
elimination from the body is interfered with. All other vegetables 
r ay be eaten with impunity. Preference should be given, on 
account of their superior nutritive values, to vegetables growing 
under ground. Salads, too, are very useful, both on account of the 
slighl laxative properties that they possess, and because they are 
usually eaten with a dressing containing abundant oil, so that in 
this way considerable fat can be introduced in a pleasant and 
palatable form. 

All articles of food made of flour, rice, cereals, may be eaten Starchy foods 
with freedom and should be given in abundant quantities, for they 
enable the ingestion of a sufficient amount of carbohydrate material 
and also permit the addition of much fat to the diet in the form of 
butter or cream. This also solves the problem of desserts, and Desserts 
patients with nephritis can eat puddings, sweets, stewed or fresh 
fruits, ice cream, etc., with impunity. 

Cheese is permissible, with the exception of those varieties that Cheese 
contain spices or that are in an advanced stage of putrefaction ; 
thus especially Eoquefort, Camembert and Parmesan cheese should 
be forbidden. 

A few rules can be formulated in regard to the beverages that Beverages 
may be permitted a case of chronic nephritis. The amount of 
liquid permitted has already been discussed above, and the relative 
advantages of drink restriction and abundant water-drinking ex- 
plained. Alcohol should be eliminated, as far as possible, from Alcohol 
the diet of nephritics, chiefly on account of the effect that this 
drug has upon the cardio-vascular apparatus; for, as has been 
repeatedly mentioned, irritation of the heart and arteries and 
elevation of the blood pressure should be avoided in chronic 
nephritis. If any alcoholic beverage at all is to be permitted, and Light wines 
this may be necessary among subjects who have been used to a 
little alcohol all of their lives, then light Moselle or Burgundy or Cordials and 
Claret diluted with some alkaline mineral water may be allowed, hquers 
Cordials, liqueurs and absinthe should be absolutely forbidden, not 
so much on account of the alcohol, but on account of the essences 
and flavors (aldehydes, etc.) that all these beverages contain, and 
that are excessively irritating to the liver and the kidneys. 

Beer is best omitted from the diet of chronic nephritics, espe- Beer 
cially if they are taking large quantities of milk. Among subjects 



360 



DISEASES OE THE URINARY APPARATUS 



Tea and coffee 



Cocoa 

Imitation cof- 
fee 

Lemonade 



Withdrawal of 
chlorides 



who have been used to drinking beer all of their lives, the occa- 
sional use of a glass of beer can, of course, do no great harm, but 
it is always safer to forbid it altogether. If beer is to be taken at 
all, stout and porter are better than German beers. 

Tea and coffee are theoretically contra-indicated in chronic 
nephritis. As the withdrawal of these beverages constitutes a severe 
hardship, however, to most persons, a little weak tea or coffee thor- 
oughly diluted with milk may be allowed, especially in the morning. 
One must be governed in the restriction of tea- and coffee- drinking 
somewhat by the individual tastes and peculiarities of the case. A 
very useful beverage, and one that can frequently take the place 
of tea and coffee, is cocoa. Some of the imitation coffees, which 
are black and sweet and hot, also have a useful place ; they certainly 
can do no harm. Lemonade and orangeade are useful beverages, 
for the citric acid they contain is converted into carbonate in the 
body and eliminated as such. 

The importance of withdrawing chlorids from the diet may be 
mentioned in this place. In nephritis the elimination of sodium 
chlorid (common salt) is often reduced. It is retained in the 
tissues, and in order to remain there in a solution that equals the 
molecular concentration of the blood and tissue juices, it must 
draw water from the blood (the less concentrated solution) into 
the tissues (the more concentrated solution) by a process of osmosis. 
This idea may in part explain the edemas of nephritis. 

On the basis of this theory the ingestion of sodium chlorid, 
i. e., common table salt, has been restricted in order to enable the 
kidneys slowly to eliminate the retained chlorids. If the theory 
were correct the edemas should disappear. 

As a matter of fact, in common with many others I have re- 
peatedly seen nephritic edemas disappear (and, incidentally, albu- 
minuria decrease) when the chlorids were excluded from the food, 
and reappear when salt was again given. 

As one hundred grains of common salt require about three 
pounds of water to form the proper physiologic solution (i. e., a 
solution exercising the proper osmotic pressure) in the body, any 
sudden increase in the weight of a nephritic patient, other things 
being equal, may mean salt retention and hence water retention 
(deep edemas), and should be an indication, tentatively at least, 
to withdraw the chlorids from the food. 

The routine administration of a salt-free diet in nephritis is, 
however, to be condemned and, before the withdrawal of chlorids 
for any prolonged period of time is undertaken, the following test 
should be made : 

The patient should be given for two days a so-called salt-free 
test diet containing small quantities of sodium chlorid and still 



DISEASES OF THE URINARY APPARATUS 361 

incorporating enough nutriment to favor adequate nutrition. The Tolerance 
main articles of diet that contain very small percentages of sodium 
chlorid are milk, cheese and unsalted butter, white bread, rice, 
poached egg, lean beef, cauliflower, mushrooms, fruits and berries. 
Canned vegetables contain more sodium chlorid than raw vegetables. 
The following table giving the percentage of chlorid in common 
articles of food may be conveniently utilized in arranging a salt- 
free diet : 

*Table of Sodium Chloride Percentages in ordinary unprepared 

foods. 
Unprepared foods with percentage of sodium chloride. 

Sodium Chloride 
in per cent. 

Milk 0.15- 0.18 

Butter, unsalted 0.02- 0.21 

Butter, salted 1.0-3.0 

Cheese 1.5 -10.57 

Egg: whole 0.13- 0.21 

yolk 0.009 

white 0.31 

Caviar 3.0 - 6.18 

Meat 0.10- 0.20 

Fresh water fish 0.06- 0.12 

Salt water fish 0.16- 0.41 

Oysters 0.52 

Bacon 1.0 

Ham 1.85- 7.50 

Meat extract 1.4 -14.6 

Mustard 2.66 

Cereals, flour, fresh vegetables, salads, fruits. 0.01- 0.10 

With the exception of 

Sago 0.19 

Oatmeal 0.26- 0.29 

Lentils 0.13- 0.19 

Lettuce 0.13 

Cauliflower 0.15 

Spinach 0.21 

Celery 0.49 

Canned vegetables (average) 0.67- 1.27 

Sauerkraut 0.73- 1.45 

Tea and coffee 0.05- 0.15 

Wine and beer containing merely traces of 
sodium chlorid. 



♦From H. Strauss: "Praktische Winke fur dde Chlorarme Erndh- 
rung." Berlin, 1910. 



362 



DISEASES OE THE URINARY APPARATUS 



Salt free 
"test meal' 



Results 



Medicament- 
ous treatment 



Indications 
for drugs 



After two days of this diet the patient is given a salt-free "test 
meal" composed as follows: 

200 g. of bread. 

200 g. of lean meat. 

250 g. of boiled vegetables. 

50 g. of salt-free butter. 

40 g. of sugar. 

1 liter of water and a little wine or coffee. 

To this test meal are added 10 g. of sodium chlorid and the 
patient's weight is studied during the next few days. If there is 
an increase in weight pointing to internal edema due to salt reten- 
tion, then the sodium chloride in the diet should be restricted. If, 
on the other hand, the weight and the edemas do not increase, then 
it is quite unnecessary to materially restrict the chlorides and every 
attempt should be made to rid the organism of surplus water by 
diaphoresis and catharsis. 

In some cases a preliminary reduction of the edema up to a 
certain point promptly occurs and one is then unable to cause a 
further reduction of the swellings by drink- and chloride-restriction 
and rest in bed alone. In such cases it is quite useless to give 
diaphoretics, because sweating rids the body chiefly of water and 
only to a slight extent of solids, so that whatever good effects may 
be obtained by sweating are purely transitory. Here, however, 
diuretics are indicated and it becomes necessary to experiment a 
little with various classes of diuretic remedies in order to determine 
which one is best suited to the individual peculiarities of each case. 
As a rule, preparations of scilla and of acetate of potash are par- 
ticularly effective. The most active drugs, however, in my experi- 
ence, have been theobromin or theocin, administered either alone or 
in combination with digitalis. 

The medicamentous treatment of chronic nephritis is of very 
subordinate importance, for we know of no remedy that can exercise 
a direct effect upon the nephritic process itself. What remedies 
are given should be administered in order to prevent constipation 
and to render the gastro-intestinal tract as nearly aseptic as pos- 
sible (see index), to exercise an effect upon the heart's action and 
the blood pressure and symptomaticalry to relieve dropsy and 
internal edemas. Most of this drug treatment it will be seen is 
directed towards improving the condition of the cardio-vascular 
apparatus; it is in all essentials identical with the treatment de- 
scribed at length in the Chapter on the Heart and Arteries. The 
symptomatic treatment of renal dropsy differs in no way from that 
of cardiac dropsy. Drugs that can be given to relieve symptoms 
about the stomach, the lungs and the central nervous system are 



DISEASES OF THE URINARY APPARATUS 363 

either discussed in the Sections on Gastro-Intestinal or Pulmonary 
Diseases or in the Chapter on Uremia. It is useless, therefore, to 
describe all these remedies again in this place. 

Drugs should, at all events, be used sparingly in chronic ne- Necessity of 
phritis, for the continuous administration of drugs is always f D arine-lv gS 
fraught with many inconveniences. In the first place the pro- 
longed use of medicine is bound sooner or later to injure those 
organs that are concerned with their absorption and elimination, 
notably, the stomach, the liver and the kidneys; and in addition 
the effect of most drugs that we might give for the sake of reducing 
the blood pressure or stimulating catharsis or diaphoresis is ex- 
ceedingly transitory and the organism soon becomes accustomed 
to them. 

It is much safer to undertake symptomatic treatment by Hydrotherapy 
hydro-therapeutic means, for, if the patient has been treated largely 
by such measures, then he always has drugs to fall back upon in 
emergencies should alarming symptoms develop that require ener- 
getic treatment. And as a rule it will be found that much smaller 
doses of the different medicines will be required in such cases to 
produce the desired effect than in patients who have been habitu- 
ated for long periods of time to the use of cardiac tonics, vaso- 
dilators, cathartics, diuretics, diaphoretics, etc. This is a great 
advantage. 

Hydro-therapy is the most efficient means for influencing the Effect on 
heart's action and the blood pressure. Three elements enter into a ^ r blood 110 " 
the physiology of arterial tension, viz., the amount of the blood, pressure 
the force of the contraction of the heart, and the degree of 
peripheral resistance. From the heart emanates the force that 
propels the blood into the arteries and causes the tension of their 
walls. The peripheral resistance, by creating an obstacle to the 
evacuation of the arteries, causes an accumulation of the blood in 
these vessels and tension of their walls with a reactive elastic pres- 
sure that propels the blood onward. The mass of blood finally is Physiology of 
the intermediary agency that driven from behind and compressed D * °d pressure 
from in front, distends the arteries to such a degree that the elastic 
powers of their walls can become operative. Increased or decreased, 
these three factors determine variations in the blood pressure, and 
all three factors can be profoundly influenced by hydriatic 
measures. 

Changes in the peripheral resistance can be brought about both Changes in 
by cold and by hot applications. In chronic arterial diseases the ^stance 1 " 3 rC ~ 
latter, however, should have the preference, for this reason: The 
application of cold always at first produces a contraction of the 
peripheral vessels, followed very shortly by a dilation called "the 
reaction." This physiological reaction that leads to reduced blood 



364 



DISEASES OF THE URINARY APPARATUS 



Hot hydriatic 
measures vs. 
cold 



Hot baths 



Salt or car- 
bonic acid 
baths 

The bathroom 



pressure cannot be utilized with safety in most cases of chronic 
nephritis; (1), because the primary contraction of the peripheral 
vessels causes a sudden increase of the arterial tension and may, in 
predisposed subjects, produce rupture of the weakened blood vessel 
walls in the brain, the retina or otherwise; (2), because the cold 
causes an increase of the heart's action by a nervous reflex that is 
transmitted directly to the cardiac ganglia; (3), because, in chronic 
nephritis, the reaction may fail altogether owing to lack of tone 
or possibly to anatomic changes in the musculature of the peripheral 
arteries, or on account of myocardial changes. 

The method of choice, therefore, for reducing the peripheral 
blood pressure is the application of heat to the body surfaces; for 
hot applications, provided the degree of temperature is not too 
high, produce from the beginning cutaneous hyperemia without 
preceding contraction of the peripheral blood vessels, and if con- 
tinued, true relaxation of the muscular coats of the peripheral 
arteries with a corresponding fall in the blood pressure. Moreover, 
heat causes a long-lasting loss of tone on the part of the peripheral 
blood vessels, in other words, a prolonged vaso-dilator effect, where- 
as the reaction following cold applications leads to what may be 
called a tonic congestion of the peripheral vessels during which the 
tone of the blood vessels is fully preserved so that contraction soon 
follows. Heat, furthermore, if applied for a sufficient length of 
time produces dilatation not only of the cutaneous vessels, but also 
of the deep blood vessels ; whereas, the dilatation of the superficial 
vessels produced by cold is usually accompanied by intense con- 
traction of the deep vessels, an effect that leads rather to high than 
to low blood pressure. The fall of blood pressure, therefore, fol- 
lowing hot applications is much more permanent and its production 
fraught with less dangers than the decrease of arterial tension 
produced by cold or by medicinal vaso-dilators. 

The simplest way of applying heat to the surfaces of the body 
for the purpose of reducing blood pressure is to give the patient 
what may be called a "hot soak," i. e., the patient is instructed 
once or twice a day (for practical purposes best early in the morn- 
ing and late at night) to lie perfectly still for five or ten minutes in 
a bathtub filled with water a few degrees below the temperature of 
the body. If it is desired to increase the effect friction may be 
applied for a time by an attendant while the patient is immersed 
in the bath. 

The addition of a few pounds of salt to the water, or immersion 
in warm carbonated water, is very useful because the salt and the 
carbonic acid both assist in relaxing the peripheral capillaries. 
The bathroom should always be kept very warm for the capillaries 
of the skin are relaxed after the bath and should be kept so as 



DISEASES OF THE URINARY APPARATUS 365 

long as possible; if the room is cold sudden contraction of the 
cutaneous vessels occurs and therewith a rapid rise of blood pres- 
sure and an increased strain upon the heart — all effects that one is 
precisely trying to avoid. In cases, moreover, in which the vaso- 
motor tone is below par, and this is common in cardio-nephritics, 
there is always considerable danger of catching cold. The best 
plan of all is to have the patient lie down in a warmed bed for a 
time after the bath. 

One other important point must further be considered in using Danger of col- 

this plan, viz., the occurrence of collateral hyperemia in various lateral . n y- 

r ' ' Jr peremia 

parts of the body, especially the brain. For this reason the head 

should always be covered with cold cloths or an ice bag during all 
the time the patient is in the water. It will be found that this plan Cold to the 
not only reduces the blood pressure for many hours thereafter, but hcad 
also slows the heart and reduces the force of its contractions. Occa- 
sionally the rapidity of the heart action is slightly increased, espe- 
cially after the patient leaves the bath. In such cases the applica- 
tion of the ice bag to the precordial region, or of cold cloths to the 
nape of the neck, may be employed to reduce the number of heart 
beats. 

A marked effect can further be exercised by hydro-therapeutic Effect on vol- 
measures upon the composition and the volume of the blood. From ume and f ° t ?" 
all that has been said above, it is clear that cold applications are blood 
absolutely contra-indicated in any case of nephritis owing to the 
«nrlden initial rise of blood pressure and the tiptvahs shook tn 
the heart that they engender. It is useless, therefore, to discuss in 
this place the interesting effect that cold applied to the surfaces of 
the body can exercise upon the percentage of leucocytes and of red 
corpuscles, and upon the specific gravity and the volume of the 
blood ; and we will concern ourselves therefore exclusively with the 
use of hot applications in order to see what effects, that may be 
beneficial in nephritis and that we usually attempt to produce by 
drugs or diet, can be produced by heat. 

Dry heat, i. e., the electric light bath or hot air, applied in Electric light 
different ways, always produces a greater concentration, i. e., a baf hs hot air 
decrease in the total volume of the blood. This is due, of course, 
to the loss of water through the sweat glands, and while this prac- 
tice by accelerating the current of lymph may act beneficially in 
the absorption of edemas, I have never been satisfied that sweat- 
ing produced in this way is beneficial in cases of nephritis with- 
out edemas ; for while some solids are lost through the sweat glands, Danger of 
the loss of water is immeasurably greater, and the concentration of dry a he?t V 
the blood is so much increased by this practice that whatever toxic 
bodies may be circulating can undoubtedly exercise a more dele- 
terious effect in a concentrated than in a diluted form. The 



366 



DISEASES OE THE URINARY APPARATUS 



Copious water 
drinking dur- 
ing the sweat 



Sweating by 
moist heat 



Hydriatic 
means to allay 
nervous irri- 
tability 



Psychic treat- 
ment 



reduction of the blood pressure that might result from a de- 
crease in the volume of blood is offset by the greater toxicity of the 
circulating fluids, for the pressor principles they contain are not 
eliminated via the sweat glands. If dry heat is applied, then the 
patient should at all events at the same time be given very copious 
draughts of water to compensate for the loss of water by diaphoresis, 
but as this practice undoubtedly throws a great strain upon the 
heart and arteries that have to pump this water from the stomach 
to the emunctories of the body, I have always felt that the benefits 
accruing from sweating by dry heat are more than neutralized by 
all these disadvantages. 

For this reason if sweating is to be produced at all it should be 
done by means of moist heat, and here the method of choice is 
without doubt immersion for five, ten or fifteen minutes in water 
heated slightly above the temperature of the body. It will be found 
that when this plan is adopted, the concentration of the blood 
does not increase, as manifested by determinations of its specific 
gravity, freezing point, and electric conductivity. It is possi- 
ble, as Wick has suggested, that the loss of water through the 
sweat glands is compensated by the absorption of water from 
the tissues, superinduced and aided by the pressure exercised 
from without by the water of the bath; at all events, immer- 
sion in hot water, aside from lowering the blood pressure by 
prolonged vaso-dilatation, causes a certain loss of excrementi- 
tious solids through the sweat glands without causing great con- 
centration of the body fluids, in other words, greater toxicity of 
the latter, and without consequently necessitating the administra- 
tion of much water by mouth. If properly carried out immersion 
in hot water really aids the body in getting rid of both solids and 
water with safety. 

In all diseases complicated by high arterial tension and an 
irregular and excitable heart action, and to this category belong 
practically all cases of chronic nephritis, it is a matter of great 
importance to allay the nervous irritability. We should always 
endeavor to do this psychically by quieting the patient's fear, try- 
ing to keep him from worrying about his condition, and advising 
him not to lead too strenuous a life, and we usually enforce this 
effect by sedative remedies. Much more can be accomplished in 
this direction with complete safety by hydro-therapeutic means. 
This fact is so well-established that nowadays the standard treat- 
ment of neurasthenia, and of many psychoses complicated with 
excitement, consists in the use of hydro-therapeutic means. As 
a rule it is impossible to carry out such treatment at home. Cer- 
tain simple measures that are of great value in quieting the 
sensibility of the whole nervous system, including the vaso-motor 



DISEASES OF THE URINARY APPARATUS 367 

nerves, can, however, be carried out in one's house, and chief 
among these, again, is the use of warm water and, by preference, the 
prolonged warm bath. 

Upon the general metabolism the use of hot water also exer- Effect of hy- 
cises a very profound influence that is particularly valuable in on t ^ G general 
nephritis. For immersion of the body in hot water for some time, metabolism 
by preventing the loss of heat by radiation, and, incidentally, by 
causing dilatation of the blood vessels supplying the muscles, 
causes an acceleration of metabolism, particularly of the non-nitrog- 
enous constituents. This is a valuable effect in nephritis as 
it prevents to a certain degree the accumulation of waste 
products in the blood and relieves the kidneys of the necessity 
of excreting them. In obese subjects a considerable loss of fat 
can be brought about in this way, especially when judiciously 
combined with proper exercise treatment, and that this is 
invaluable in any form of cardio-renal disease need hardly be em- 
phasized. 

The use of dry heat is again not safe on account of its effect 
upon metabolism, because the body at once consumes an in- 
creased amount of its own nitrogenous constituents to make up 
for the loss of heat by radiation; in this way flooding of the 
blood stream with urea and bodies that are intermediary between 
albumen and urea is brought about. Whenever this occurs in- 
creased labor is thrown upon the kidneys, as they must rid the 
organism of this circulating waste material. 

Upon the digestion, i. e., upon the secretory and motor function Effect on di- 
of the stomach and bowels, hydriatic procedures also exercise a sestion 
profound influence. Unfortunately, however, the measures that 
are most efficacious in promoting increased secretion and improved 
motility are cold hydriatic means, and these we cannot employ. 
The one cold measure that is useful and that can be applied 
with safety is the application of cold locally over the liver, 
either in the form of a Priesnitz compress or by means of a 
cold stream of water directed against the hepatic region with 
the rest of the body protected. This process stimulates the he- 
patic function and promotes an increased flow of bile. In view 
of the presumably hepatic origin of many forms of Bright^ 
disease, this is a useful adjuvant to treatment, especially since 
the entrance of much bile into the upper portion of the bowel re- 
duces intestinal putrefaction. This is one of the most desirable 
effects that can be obtained in nephritis, an effect that we 
usually attempt to bring about by dietetic and medicinal 
means. 

In conclusion a word should be said in regard to the effect of Effect on the 
hydriatic procedures upon the flow of urine. Cold applied to flow of unne 



368 



DISEASES OF THE URINARY APPARATUS 



Signal ad- 
vantages of 
proper hydro- 
therapy in the 
treatment of 
chronic neph- 
ritis 



Climate and 
altitude 



the surfaces of the body, as is well known, stimulates diuresis both 
by raising the blood pressure and presumably also by a reflex ac- 
tion upon the musculature and the sensory nervous apparatus of 
the bladder. This becomes manifest by the almost instantaneous 
desire to urinate that patients develop as soon as cold meas- 
ures are applied. As cold is inadvisable in nephritis, we cannot 
make use of this procedure, but I do not consider this a disadvan- 
tage, for I have never been convinced that the stimulation of 
diuresis is a desideratum in nephritis. Any measure that increases 
the flow of urine by implication stimulates, even irritates, the 
kidneys, immaterial whether the stimulus be a drug acting directly 
upon the secretory mechanism of the kidneys or upon the blood 
pressure within the kidneys. When the kidneys become diseased 
they at once fail, as shown above, to eliminate certain bodies prop- 
erly, but to force them to eliminate, nevertheless, is a pre- 
carious procedure for it violates one of the fundamental principles 
of the treatment of a functionally inadequate organ, viz., that this 
organ should be rested rather than irritated and forced to work. 
For rest alone will enable Nature to institute the necessary re- 
parative processes and to hasten recovery. Consequently heat is 
again useful for it lowers the blood-pressure in the kidneys and 
consequently may somewhat reduce diuresis, but it also spares the 
kidneys by soothing rather than irritating the nervous ap- 
paratus that superintends the manufacture and excretion of urine. 

It will be seen, therefore, that such simple measures as hot 
bathing, properly administered, and the application of hot or cold 
to various portions of the bod}', can accomplish much in the 
treatment of the nervous, metabolic, gastro-enteric and cardio- 
vascular manifestations of nephritis that we ordinarily attempt 
to remedy by drugs. 

In selecting a climate its effect upon the skin should be con- 
sidered ; preference should be given to a climate in which the daily 
temperature fluctuations are very small, in which the altitude is 
low and the atmosphere dry ; for such a climate stimulates insensi- 
ble perspiration, so that the kidneys are relieved of some of the 
labor of excreting water; moreover, the surfaces of the body are 
not alternately heated and chilled, consequently there is less dan- 
ger of catching cold and less probability of disturbing the vaso- 
motor equilibrium and hence causing congestion of the diseased 
kidneys. Otherwise the choice of a resort or a climate should 
be governed by the condition of the heart and arteries (see index) . 
In Europe, chronic nephritics are sent to Egypt, Algiers, Cor- 
sica and the Riviera. In the United States, Southern California, 
Arizona and New Mexico furnish the most ideal locations for this 
class of cases, 



DISEASES OF THE URINARY APPARATUS 369 

The regulation of exercise and the administration of massage Exercise 
likewise are dependent on the state of the cardio-vascular ap- 
paratus more than of the kidneys. For a discussion of this part 
of the treatment I refer, therefore, to the Chapter on Diseases of 
the Circulatory Apparatus. 

One word may be said in conclusion concerning the so-called Surgical 
surgical treatment of Bright's disease. Splitting of the kidney Bright's dis- 
capsule, or decapsulation of the organ, for the cure of Bright's ease 
disease is altogether irrational. The temporary relief of tension 
may improve the blood supply to the kidneys, and hence restore, 
for the time being, some functional activity to diseased epithelia; 
and this improvement in the renal function may become mani- 
fest by a reduction of the edema, by a transitory decrease in the 
albuminuria, the disappearance of formed elements (casts, etc.) 
from the urine, and an increase in the execretion of solids and of 
water. Bright's disease, however, as we have seen in the preceding 
paragraphs, is a systemic disorder and the nephritis is merely one 
of its symptoms. Any treatment of the kidneys alone, whether 
surgical or otherwise, is, therefore, purely symptomatic, and can 
in no sense be regarded as curative. One might as well amputate 
the rose spots in typhoid fever and expect to cure the disease. It 
is not surprising to find, therefore, that no true case of Bright's 
disease has even been permanently benefited by operations on the 
kidneys. The procedure is mentioned in this place merely to be 
condemned. 



PYONEPHROSIS AND PYELITIS. 

Pyonephrosis and pyelitis are rarely primary disorders. As a 
rule they are consecutive either to calculus disease, or they de- 
velop by ascending infection from some disorder of the lower 
genito-urinary passages. Occasionally they are blood-borne, as, 
for instance, in tuberculosis, typhoid, pneumonia, scarlet fever, 
diphtheria and small-pox. Carcinoma and sarcoma, and occasion- 
ally s}^philis, also produce pyelitis, possibly by weakening the 
resistance of the tissues and thus rendering them susceptible to 
infection. 

The causal and prophylactic treatment of pyelitis must take Causal and 

all these pathogenetic elements into consideration. Thus in some prophylactic 

ii n o treatment 

cases the same rules apply as in the treatment of nephro-lithiasis, 

disorders of the bladder, urethra and female genitalia. Treatment 
directed towards preventing pyelitis in infectious diseases con- 
sists in promoting a copious diuresis and advancing every effort to 
reduce the toxicity of the urine and increasing the resisting pow- 



370 



DISEASES OE THE URINARY APPARATUS 



Counter-irrita- 
tion over 
Petit's tri- 
angle 



Catharsis 



Diet 



Astringents 



Urinary anti- 
septics 
Urotropin 



Sodium ben- 
zoate 
Copaiba 
Juniper oil 



ers of the renal and pelvic tissues. The inflammation within 
the renal pelvis can be favorably influenced by the application of 
leeches or cups over Petite triangle, i. e., that area which is 
bounded by the crest of the ilium, the latissimus dorsi and the ex- 
ternal abdominal oblique muscles, for the veins of this region con- 
nect directly with the veins of the renal capsule, so that counter- 
irritation, bleeding or cupping over Petit's triangle can exercise an 
important effect upon congestion within and around the kidneys. 
In addition the bowels should be kept freely open by the use of 
laxatives, preferably of a vegetable character. In this way revul- 
sive action is promoted and at the same time the absorption of 
bowel toxins that might be irritating to the kidneys in their pas- 
sage into the urine prevented. 

The diet should be bland and non-irritating and consist largely 
of milk. Here the principle of sparing the kidneys that is so im- 
portant in most renal disorders of an acute and sub-acute char- 
acter, obtains with particular force, for the kidneys must be en- 
abled to put forward every effort towards combating the local 
inflammation. The diet should consequently be arranged in the 
same way as outlined under Acute and Subacute Nephritis. There 
is one exception to this rule, viz. ? cases of pyelitis without ne- 
phritis should always drink plenty of water in order to dilute 
the urine and thus flush the kidney channels and the pelvis, pre- 
vent ascending infection and stagnation and mechanically, in 
case the presence of calculi is suspected, promote their expulsion. 

In the latter case, provided it is possible to determine the 
composition of the concretions from fragments that may be passed 
or from other urinary signs, the same dietetic rules should be ob- 
served as described under Nephrolithiasis. 

In the more chronic varieties astringents, chiefly tannigen, in 
doses of from ten to thirty grains (0.6 to 2 gm.), or catechu, pre- 
ferably in the form of the compound catechu powder, containing 
catechu, kino, krameria, cinnamon and nutmeg, in doses of from 
ten to seventy grains a day (0.6 to 2.4 gm.) may be given. 

In this disease, finally, urinary antiseptics have the widest field 
of application. Best of all is urotropin, which may be given in 
doses of from three to ten grains (0.2 to 0.6 gm.) in a full glass 
of water, three or four times a day. The addition of 10 drops of 
dilute hydrochloric acid to each glass of water enforces the action 
of the urotropin and is advisable. 

Benzoate of soda^ in doses from five to thirty grains (0.3 to 
2 gm.) in water; the oil of copaiba, in doses of from ten to fifteen 
minims (0.6 to 1 cc.) in capsules; the oleum cadinum (empyrheu- 
matic oil of juniper) in the same doses, are all useful. 



DISEASES OF THE URINARY APPARATUS 



371 



Finally, salol, in doses of from five to fifteen grains (0.3 to 1 
gm.) in capsule or powder, or, the sulphocarbolate of sodium in 
from five to fifteen grain (0.3 to 1 gm.) doses three or four times 
a day can also be employed. Methylene blue is without effect. All 
of these remedies should be taken with abundant water and in 
using any of them great care should be exercised not to produce 
renal irritation. Their prolonged use is, as a rule, somewhat 
dangerous, hence the urine should always be carefully examined 
for casts or other evidence of nephritis. As soon as such signs 
appear the administration of these drugs should be interrupted or 
stopped.* 

The pain in pyelitis should be treated in the same manner as 
the pain in nephrolithiasis and renal colic. 

In cases of very severe suppuration that do not yield to medica- 
mentous treatment, combined with the proper diet, hygiene and 
rest, surgical intervention may become necessary, consisting in 
drainage of the kidney, removal of concretions that may be present, 
or even nephrectomy. 

Of recent years still another method of treating pyelitis has 
been devised, consisting in the introduction of a ureteral catheter 
and the injection of various astringents and antiseptics directly in- 
to the renal pelvis. This is called lavage of the renal pelvis. 



Salol 

Sodium sulpho- 
carbolate 
Methylene blue 



Pain 



Surgical treat- 
ment 



Intra-pelvic 
medication 



THE TREATMENT OF PYELITIS BY LAVAGE OF THE RENAL 
PELVIS. 

(By Dr. F. Kreissl, Chicago.) 
Lavage of the renal pelvis is performed by injecting medicated Instruments 
fluids into the pelvis through a ureter-catheter, introduced by em P lo y ed 
means of a cystoscopy The direct or indirect view catheterizing- 
cystoscope may be employed. In the male the direct view cysto- 
scope no doubt causes more tension and traumatism to the pros- 
tatic urethra than the indirect view instrument. The former, also, 
will be found inadequate where the ureteral os, as quite fre- 
quently happens, is located close to the vesical sphincter. On the 
other hand it will generally be found that the passing of the 
catheter into the ureter is more readily accomplished with the 
direct view cystoscope, for here the curve from the instrument to 
the ureteral os is eliminated. For the purpose in question a cysto- Technique 
scope should be employed which can be removed without disturb- 
ing the position of the catheter in the renal pelvis. The catheters 
used should have moderately blunt points, and should be introduced 
without undue haste in order to avoid traumatism. Renal lavage, 
if carried out carefully, and under strictly aseptic precautions in 
every detail is a harmless procedure. 



*For autogenous vaccination in chronic pyelitis see page 



372 



DISEASES OF THE URINARY APPARATUS 



Solutions em- 
ployed 



Quantity to be 
injected 



Frequency of 
applications 



Leaving the 
catheter in 
place 



Limitations of 
the method 



Suppurative 
pyelitis 



The solutions most commonly employed are a warm solution 
of boric acid, 4 to 100; oxycyanide of mercury, 1 to 4,000; ni- 
trate of silver, 1 to 2,000 to 1 to 1,000 ; protargol 1 per cent, and 
argyrol, 5 to 20 per cent. Of the silver solutions mild concen- 
trations should be used at first, gradually increasing their strength 
from treatment to treatment. 

The quantity to be injected must vary with the capacity of 
the renal pelvis in each individual case; however, so much should 
never be injected as to cause over-distension and colicky pains. 
In the majority of cases I have found injections of 4 to 8 cc. at a 
time sufficient. 

The intervals that should elapse between each application de- 
pend on the nature and the extent of the local trouble. If there 
is much debris in the renal pelvis it will be necessary to perform 
preliminary irrigation with a warm boric acid solution until the 
fluid returns fairly clear, and then to inject the antiseptic; while 
in cases with little pus in the urine, the antiseptic may be de- 
posited at once without a preceding cleansing irrigation. 

Where the conditions require daily renal lavage in male pa- 
tients I always prefer leaving the catheter in situ for a few days 
at least; this permits frequent topical application without unneces- 
sary and inevitable traumatism to the prostatic urethra incident to 
repeated introduction of the instrument. 

The extravagant claims which have been made for this method 
of treatment are not supported by facts, but it certainly has a 
definite, though limited sphere of usefulness. To appreciate this 
the following points may be considered: Etiologically pyelitis, or 
rather pyelonephritis, is more frequently caused by a descending or 
hematogenous, than by an ascending or urogenous, infection. If 
the suppuration be of hematogenous origin, the kidney parenchyma 
must have been first infected, and it is hard to understand how a 
topical application to the renal pelvis can effectively reach the focus 
in the kidney proper. And the same objection must reasonably be 
made to the efficacy of the method in the ascending type of pye- 
lonephritis. At best one can expect some relief of those s}^mptoms 
which are due to abnormal conditions in the renal pelvis and are 
directly traceable to the infection and inflammation existing in that 
locality as, e. g., retention of pus and urine arising from inflamma- 
tory swelling or blocking of the ureteral openings, renal colic from 
distension of the pelvis and fever. 

Cases of suppurative pyelitis without involvement of the kid- 
ney proper constitute only a small fraction of the cases of pyelitis 
that come under observation; this is partially explained by the 
generally accepted fact that hematogenous infection is the more 
common cause of pyelitis than urogenous infection; perhaps also 



DISEASES OF THE URINARY APPARATUS 373 

by the absence or the mildness of perceptible symptoms in initial 
stages of the disease that render its early discovery rare. This also 
explains the fact why we do not often see cases before the kidney 
Darenchyma has been invaded. 

Another point to be considered is that many of these cases Complications 
either are caused by or complicated with calculus, malforma- 
tions of the renal pelvis, strictures or other obstructions in the ureter 
and urethra, tuberculosis, tumors, etc., so that renal lavage can, 
at best, give only temporary relief, while suitable and well di- 
rected surgical measures will usually obviate the necessity of any 
topical application. 

Furthermore, the vast majority of uncomplicated cases of pye- Spontaneous 
litis heal spontaneously, or under the use of the internal agents complicated Un " 
discussed in previous paragraphs of this section. Almost the only pyelitis 
exceptions to this rule are ascending gonorrheal infections of the 
renal pelvis. These cases are not so rare as is commonly believed 
and they do not yield to conservative treatment, while renal lavage Gonorrheal 
with efficient silver solutions has generally given me surprisingly 
good and rapid results. Frequently, however, especially in older 
cases the gonococcus appears associated with bacterium coli, staphy- 
lococcus and other germs; if properly treated the gonococcus in 
such cases disappears permanently from the renal pelvis, but I 
have never succeeded in a single case of this kind in clearing the 
urine thoroughly or permanently of the other bacteria. This leads 
me to the conclusion that renal lavage is not effective in mixed in- Renal lavage # 
fections of the pelvis, or else that the gonococcus has a tendency J^ed hifec- 
to locate in the pelvis, while the other germs invade the kidney tions 
proper where topical applications do not reach them. 

Summing up my experience with renal lavage in many cases of Summary 
divers types of pyelitis and pyelonephritis, I recommend its use as 
a curative agent in pyelitis uncomplicated by nephritis, stones or 
strictures, and then only when the ordinary means of internal 
medication fail to remove the suppuration. 



NEPHROLITHIASIS. 

The treatment of nephrolithiasis must concern itself, first, Indications for 



with preventing the deposit of concretions in cases that are pre- 
disposed to the formation of renal stones; second, with facilitating 
the passage of the concretions after they have once formed; 
third, with preventing secondary infections and, lastly, with symp- 
tomatically relieving the pain, the renal colic, the hematuria and 
other phenomena. 



treatment 



374 



DISEASES OF THE URINARY APPARATUS 



Prophylaxis The prophylactic measures that we can employ vary accord- 

ing to the character and the composition of the urine. Thus 
an individual voiding an acid urine, with occasionally a little gravel 
or sand composed of uric acid, urate or v oxalate crystals, must be 
treated differently from a subject whose urine is alkaline and pos- 
sibly purulent; for, in the latter, we have every reason to dread 
the formation of phosphatic deposits. Of the many concretions 
that can form in the urinary passages the most important varieties, 
and those that, alone, in the light of our present knowledge, are 
amenable to causal and prophylactic treatment, are uric acid and 
urates, oxalates and phosphates. 



NEPHROLITHIASIS URICA. 



Four factors 
that determine 
solubility of 
urinary uric 
acid 



Diet 



Alkalies 



To prevent uric acid or urate deposits the solubility of the 
urinary acid must be increased ad maximum. The factors that 
chiefly* determine this solubility are the concentration of the 
urine, the percentage of uric acid it contains, its content of sodium 
chloride and above all its reaction. The more concentrated the 
urine and the more uric acid and sodium chloride it contains 
percentically the greater the tendency to the precipitation of uric 
acid and urates in the urinary passages. 

For these reasons the urine should always be rendered dilute 
by abundant ingestion of water; the urinary excretion of uric acid 
should be reduced as much as possible by proper dietetic and medic- 
inal means, as described in full in the Chapter on Diseases of Meta- 
bolism, and, finally, the intake of sodium chloride, i. e., of com- 
mon table salt, should be restricted. 

The most important element in the prophylactic treatment of 
nephrolithiasis urica, however, is the regulation of the reaction of 
the urine, for it is a well established fact that the alkaline urates 
are more soluble than acid urates or uric acid itself. To render 
the urine less acid and to promote the solubility of uric acid, al- 
kalies, i. e., chiefly sodium carbonate and bicarbonate, or alkaline 
mineral waters, are commonly given in nephrolithiasis urica. It 
must be remembered, however, that the action of alkalies in cold 
urine, or even in normal urine, as studied in the test tube, differs 
materially from their effect on a highly concentrated urine, such 
as we find it in nephrolithiasis urica, in which the gravel deposits at 
body temperature. The changes in the reaction of the urine, 
moreover, that are seen after the administration of alkalies must 

*In all forms of nephrolithiasis there must also be a cement- 
ing material (mucus, fibrin, pigments, etc.) that makes a concre- 
tion out of a fine sediment. 



DISEASES OF THE URINARY APPARATUS 375 

be interpreted with great care if urinary titration methods are em- 
ployed, for here many sources of error creep in that need not 
however be discussed in this place. 

The most important influence undoubtedly exercised by the Effect of alka- 
administration of alkalies upon the solubility of uric acid in t i on f differ^' 
the urine is the change in the relative proportion of acid, neutral en * urinary 
and basic phosphates in the urine that they bring about. For 
urio acid is readily soluble in basic phosphates (di-sodium phos- 
phate) ; the addition, in fact, of mono-sodium phosphate to a so- 
lution of uric acid in di-sodium phosphate will cause the precipi- 
tation of uric acid. It is clear, therefore, that the solubility of 
uric acid in the urine is enhanced by the presence of di-sodium 
phosphate, and that the tendency to the formation of uric acid 
concretions increases in proportion to the amount of acid phos- 
phate that is excreted through the kidneys. It is also clear that 
any effort directed towards preventing the precipitation of uric 
acid in the urinary passages must be concerned with increasing 
the amount of basic, and decreasing the amount of acid, phosphates. 
The ideal would be to cause the complete disappearance from the 
urine of mono -phosphate and, at the same time, to produce an 
elimination through the kidneys of a quantity of di-phosphate suf- 
ficiently large to hold all the uric acid excreted in solution. This 
can be accomplished in two ways, viz., either by decreasing the 
phosphoric acid in the blood that enters the kidneys or by increas- 
ing the sodium in this blood. The latter object can be accom- 
plished by sodium salts but better still, as will be presently shown, 
by calcium salts. 

To decrease the phosphoric acid its source must be considered; The decrease 
it may be derived from preformed phosphates ingested with the IJcicf in^he* 00 
food or from the phosphorus contained in the albumins (chiefly urine 
nucleins) of the food or the body tissues proper that is converted, 
by intra-cellular oxidation, into phosphoric acid. By eliminating 
from the diet, on the one hand, pabulum containing preformed 
phosphates or nuclein-containing food, and by removing, on the 
other hand, from the blood and tissues, through other channels 
than the kidneys, the phosphoric acid that must inevitably be 
formed from the degradation of our own tissues, we can reduce the 
urinary phosphate excretion. 

We possess a remedy that can both directly and indirectly regu- 
late the phosphoric acid content of the blood and hence of the 
urine, viz., calcium salts.* For, in the first place, calcium forms in- Calcium as a 
soluble salts with the alkaline phosphates contained in our normal remea y 



*Croftan: The Use of Calcium Salts in Nephrolithiasis, etc. 
'Jour. A. M. A.," 1904. 

*See Croftan: "Clinical Urinology" (Cleveland Press). 



;?6 



DISEASES OF THE URINARY APPARATUS 



Mode of action 
of calcium 
salts 



Dangers of 
continued al- 
kali therapy 



Advantages of 
calcium salts 



Dose and ad- 
ministration 
of calcium 
salts 



food, and in this Avay prevents the absorption of this moiety 
into the blood. In the second place calcium, owing to the great 
affinity it possesses for phosphoric acid, combines with the phos- 
phoric acid encountered in the blood stream, and causes the elim- 
ination of this proportion in the form of calcium phosphate — not, 
however, through the kidneys, but in great part through the intes- 
tine. This is an important point, for, in contradistinction to 
sodium, potassium and magnesium, all elements that are chiefly 
eliminated through the kidneys, calcium is principally (85 to 95 
per cent.) eliminated through bowel. 

It will be seen, therefore, that calcium given by mouth can, 
first, prevent the entrance of a certain proportion of preformed 
phosphoric acid (phosphates) from the food into the blood, and 
can, secondly, prevent some of the phosphoric acid formed in the 
organism from passing into the urine by causing its elimination 
through the intestine. 

In order to increase the sodium (or potassium) in the renal 
blood, sodium (or potassium) salts, as stated above, are com- 
monly administered; but this practice is not without its dangers, 
for it may produce alkalinization of the urine and therewith 
create a tendency to the formation of phosphatic deposits (see be- 
low) upon the uric acid or urate stones. When this occurs the 
concretions usually grow rapidly and more harm is done than 
good. Whenever an alkali therapy is employed, therefore, 
care should be taken above all things to keep the urine faintly 
acid. This is difficult when sodium (or potassium) salts are 
given for long periods of time; their continued use, moreover, 
exercises a deleterious effect upon the gastric digestion and is 
not without effect upon the corpuscular elements of the blood. 
Calcium salts, on the other hand, never render the urine alkaline 
and are fully as efficacious as sodium or potassium salts for they, 
as shown above, cause a relative increase of the sodium and 
potassium and hence of the sodium (potassium) di-phosphate of 
the urine. They are, therefore, the best prophylactic remedies 
in nephrolithiasis, either alone or in combination with 
small quantities of sodium carbonate and, above all, with plenty of 
water. 

The best calcium preparation is the carbonate. This may be 
given in doses of fifteen to twenty grains, three times a day. More 
may be given with impunity. It is necessary to individualize. The 
smallest efficient quantity of any drug is always the best dose. 
The urinary calcium, phosphorus and uric acid excretion can to 
advantage be determined in the beginning (the patient being on a 
fairly constant nuclein-free diet) and the dosage regulated ac- 
cordingly. 



DISEASES OF THE URINARY APPARATUS 377 

A more convenient method of administering calcium, and one Mineral wa- 
that is preferred by most patients, particularly if the treatment is calcium* 1 aminB 
to be carried out indefinitely, is to give calcium in the form of nat- 
ural mineral waters or as an addition to some pure water. Among 
the better known European mineral waters Contrexeville, Wildun- 
gen and Faehingen contain the largest proportion of calcium salts. 
Among domestic waters the choice is difficult. The exploiters of 
the majority of them make such blatant and extravagant claims in 
regard to wonder cures that it is not safe to place any reliance on 
this essentially commercial propaganda. Personally, I prefer add- 
ing the necessary amount of calcium salt or lime water to some 
pure water. 

A word may be said in this connection in regard to certain uric acid 
other remedies that have been recommended from time to time as solvents 
so-called uric acid solvents. In most cases these remedies are 
given because they possess the property of dissolving uric acid in 
the test tube. One is not justified in deducing from this fact that 
they can also dissolve uric acid in the body, especially after urates 
have crystallized out or concretions have once formed. 

This applies with particular force to the alkalies that have just 
been discussed. They do not possess the power of dissolving urate 
concretions in the renal passages or otherwise in the body, but they 
act prophylactically by increasing the solubility of the circulating 
uric acid and preventing its deposit. They may also act beneficially 
by promoting general oxidation, and they finally possess a certain 
diuretic effect which is useful. 

It is preposterous to give alkalies or any other remedies with Fallacy of _ giv- 
the idea that they will dissolve urate concretions. One might as sofvents' 301 
well give ether to dissolve the fat of the body in obesity, or min- 
eral acid to dissolve the calcium out of osteophytes, on the ground 
that ether or acids can dissolve fat or calcium salts in the test 
tube. The amount of ingested alkali, moreover, that actually 
reaches the uric acid deposits (which are usually covered with a 
thin layer of mucoid material that protects them from "solvents") 
is so small that a solvent effect can impossibly be accomplished. 

This criticism applies with particular emphasis to lithium Lithium 
preparations that are so popular in the treatment of uric acid 
diseases. In the first place so-called lithia waters contain only 
a few decigrammes of lithium carbonate to the litre. As they 
always also contain large quantities of other alkalies only a very 
minimal amount of uric acid (according to Barthollefs law) would 
at best combine with the lithia, the bulk with the sodium and 
potassium salts, while, at the same time, most of the lithium would 
be promptly excreted as chloride, phosphate and sulphate. Finally, 
lithium carbonate, which actually does readily dissolve uric acid 



378 



DISEASES OF THE URINARY APPARATUS 



Lysidin, sido- 
nal, piperazin 



Urea 



Sodium ben- 
zoate 



Urotropin 



Borovertin 



Glycerin 



in the test tube, is immediately converted in the stomach into 
lithium chloride, a salt that possesses only slight uric acid dis- 
solving properties. 

Other preparations that have been recommended as uric acid 
solvents are lysidin and sidonal (the quinic acid salt of piperazin). 
I have never been able to convince myself that either of these 
remedies exercise any solvent effect whatsoever in nephrolithiasis 
urica. Urea too is considered a uric acid solvent, and it actually 
possesses the power to a very marked degree of dissolving uric acid 
outside of the body. Clinically, however, the results obtained 
from the administration of large amounts of urea have been, on the 
whole, unsatisfactory. What beneficial effect it occasionally exer- 
cises in ridding the renal passages of small concretions must pre- 
sumably be attributed to its marked diuretic action. Benzoic acid 
in the form of sodium benzoate, in doses of five to thirty grains 
(0.3 to 2 gm.) in water has been extensively used. It does not dis- 
solve urate concretions, but it acts as a urinary antiseptic and hence 
may prevent infection of the urinary passages, with disagreeable 
secondary consequences like pyelitis. Other urinary antiseptics 
have been discussed in the part on Pyelitis. 

Urotropin (hexamethylentetramine) is probably the only remedy 
that in a measure has vindicated its claim to being a uric acid 
solvent in nephrolithiasis. It splits off formaldehyde in the body 
and the latter combines with uric acid to form a soluble compound. 
It has also been shown that the urine of patients who have taken 
large doses of urotropin acquires the power to a marked degree 
of dissolving uric acid. Urotropin is, besides, a very effective urin- 
ary antiseptic, so that it truly deserves extended trial in nephro- 
lithiasis urica. It should be given in five to ten grain doses, in a 
full glass of water, two or three times a day. 

Borovertin, a combination of uric acid and hexamethylene- 
tetramin, is useful wherever urotropin is indicated and possesses the 
power of acidifying the urine more than urotropin does, hence 
probably exercises a greater bactericidal power than the former. 
As a prophylactic measure against urinary infection in prostatic 
hypertrophy and in patients who have to use the catheter frequent- 
ly, it is very valuable. 

One of the most useful remedies to promote the expulsion of 
concretions that we possess, aside from diuretics and abundant 
water-drinking, is glycerin. It should be given in large doses of 
50 to 100 cc, in lemonade or water. Its mode of action is not 
well understood, but symptomatically it certainly sometimes aids 
in the expulsion of small concretions. The urine should, how- 
ever, always be carefully examined for evidence of renal irritation, 
for in certain subjects glycerin produces hematuria; so that as 



DISEASES OF THE URINARY APPARATUS 379 

soon as blood appears in the urine, the administration of glycerine 

should be stopped. Olive oil, too, has been used for this purpose. Olive oil 

For relieving the pain in nephrolithiasis either heat or cold or The relief of 

counter-irritants may be applied to the lumbar region. In the rena p 

. . „ , , , . „ Heat and cold 

dull pain that is so characteristic of a large stone, heat is usually 

more grateful than cold, whereas in the acute paroxysm of pain 

in renal colic, cold usually affords greater relief than heat. 

Turpentine or tincture of belladonna (a few drops on flannel Local applica- 
wrung out of hot water) applied locally to the lumbar region help pent ine and 
the dull ache, but exercise no effect upon the colic. belladonna 

In severe renal colic opium will usually have to be given, either Opium 
hypodermically as morphine, in doses of one-fourth to one-half 
grains, or by rectum in the form of a suppository or a starch 
enema. Chloral hydrate, ten to twenty grains (0.6 to 1.2 gm.) chloral hy- 
by rectum, also frequently relieves. The patient can to advantage drate 
also be placed into a warm bath or into bed with hot water bags 
to the lumbar region. If these simple measures fail to bring re- 
lief, then a few whiffs of cholorform will occasionally not only Chloroform 
stop the colicky pain, but actually facilitate the passage of the 
calculus by producing relaxation of muscular spasm. 

Eenal hemorrhages, if slight, should be treated by rest in bed, Renal hem- 
while the bowels are thoroughly evacuated and the patient is kept orrn age 
on a milk diet. At the same time certain drugs may be given, 
especially if the hemorrhage becomes obstinate and very severe. 
The most useful drugs are the fluid extract of ergot in fifteen to 
thirty drops (1.0 to 2.0 gm.), or preferably the injection of ergot Ergot 
hypodermically, using ergotin, one part, and camphor water, two 
parts, in doses of three to ten drops (0.15 to 0.65 gm.). The oil 
of erigeron, fifteen to thirty drops (1.0 to 2.0 gm.) in capsule Erigeron 
may be used if there is no nephritis. Tannigen, ten to thirty Hydrastis 
grains (0.6 to 2.0 gm.) in powder; the fluid extract of hydrastis, 
fifteen to sixty minims (1 to 4 cc), or better the hydrochlorate 
of hydrastinin, given hypodermically or by mouth, in doses of 
one-half to two grains (0.3 to 0.1 gm.) repeated, are all useful 
remedies. 

In case the medicamentous and dietetic measures, combined 
with rest, fail to stop the pain and hemorrhage; if the attacks of 
renal colic persist or if severe suppurative pyelitis complicates the Surgery in 
disorder; or, finally, if a calculus becomes impacted in a ureter so 
that the patient's life is endangered from mechanical anuria, then 
recourse must be had to surgical means. 



3 (SO DISEASES OF THE URINARY APPARATUS 

NEPHROLITHIASIS OXALURICA. 



Relation of 
oxalic acid to 
uric acid and 
dextrose 



Diet 



Articles of 
food contain- 
ing oxalic 
acid 



Special articles 
of diet 



Abundant wa- 
ter drinking 



Nervous dys- 
pepsia and 
oxaluria 



Symptomatic 
treatment 



Uric acid and oxalic acid are chemically closely related. There 
is also a peculiar relationship between dextrose and oxalic acid 
that is not altogether understood; clinically we know, at 
all events, that many cases of mild diabetes develop oxaluria and, 
chemically, we know that dextrose can be converted into oxalic 
acid. 

The diet consequently should be arranged in such a way as 
to take into consideration both the factors that may determine 
increased uric acid secretion and glycosuria. Besides all articles 
of diet should be excluded from the bill of fare, or greatly re- 
duced, that contain preformed oxalic acid. Chief among the lat- 
ter are tea, cocoa, spinach, gooseberries, rhubarb, figs and pep- 
per; in addition, coffee, chocolate, chicory, red beets and toma- 
toes, the last named articles, however, containing only very 
small quantities. Champagne and beer also seem to lead to an 
increased oxalic acid excretion. In cases, moreover, that show 
a decided tendency to oxalate deposits, sugar, sweets, cereals, vege- 
tables growing underground, and all starchy foods should be re- 
duced. 

Meat (with the exception of nuclein-containing organs, i. e., 
raw, rare and cured meats, meat extracts and bouillons), eggs, 
green vegetables, salads, plenty of milk and fat, in any form, 
should constitute the chief articles of diet. In addition much 
water should be taken, preferably between meals, on rising and 
on retiring. The addition of a little soda to the water, or drink- 
ing alkaline mineral waters, is a useful adjuvant to the treat- 
ment. 

As many cases of nervous dyspepsia, chiefly hyperacidity of 
the stomach, seem to develop oxaluria, particular attention should 
always be paid to this condition according to the rules that are 
discussed in another chapter. 

The symptomatic treatment of oxaluria is the same as that 
previously discussed under the heading of Nephrolithiasis Urica. 



NEPHROLITHIASIS PHOSPHATICA. 



Etiological 
treatment 



Phosphate concretions occur only when the urine is alkaline. 
As a rule they form upon a pre-existing urate or oxalate calculus, 
or upon some organic debris in the kidneys, the pelvis, the ureters 
or the bladder. Phosphate concretions are consequently most com- 
monly found in inflammatory, purulent disorders of the urinary 
passages, particularly if there is some stagnation of urine. Treat- 



DISEASES OF THE URINARY APPARATUS 381 

ment, especially in this form of nephrolithiasis, should hence 
be directed principally towards rendering the urine aseptic, to- 
wards preventing its stagnation and towards combating 
the existence of pyelitis or cystitis, according to the meth- 
ods spoken of in appropriate sections. Phosphate stones can- 
not be dissolved by any known means after they have once 
formed. 

There is also an indistinct metabolic perversion which leads Diabetes 
to an increased excretion of phosphorus, so-called Diabetes Pfoos- phosphaticus 
phaticus, in which basic phosphates are excreted in great excess. 
This, in the obscurity of our present knowledge, we are unable 
to influence. 

An attempt should always be made in phosphate lithiasis to Muriatic acid 
render the urine less alkaline and this can best be done by admin- 
istering by mouth muriatic acid (Acid hydrochlor. dil. — close 
five to thirty drops in water t. i. d.), or, paradoxical as it may 
sound, phosphoric acid (Acid phos. dil. — dose five to twenty Phosphoric 
drops, twice or three times a day in water). acid 

The symptomatic treatment of pain, colic, hemorrhage, etc., Symptomatic 
and the indications for surgical intervention are the same as in 
other forms of nephrolithiasis. 

FLOATING KIDNEY. 

Unless the dislocation of the kidney is due to trauma or spinal Causes 
curvature, abnormal motility and abnormal location of the organ 
are generally a part symptom of a general gastro- and enteroptosis. 
Floating kidney is found much more frequently in women than 
in men. This is due to a number of causes ; the wearing of corsets 
and tight waistbands; pregnancy with resulting changes in the 
intra-abdominal pressure; dislocation of the uterus and its adnexa 
exercising a direct pull by continuity upon the ureters and kidneys. 
The right kidney is more frequently dislocated than the left, both 
in men and women, first, because it is normally somewhat more 
motile than the left; second, because the left renal artery is 
shorter than the right and is more intimately connected by the 
suprarenal vein with the suprarenal gland than on the right side ; 
third, because the pancreas gives some support on the left side, 
and, fourth, for the reason that tight lacing is more apt to loosen 
the right than the left kidney, as on the right side the solid and 
unyielding liver lies between the waist and the kidney, whereas 
on the left side the hollow stomach forms a yielding and elastic 
cushion that does not transmit the pressure exercised from above. 

In the great majority of cases the increased motility of the kid- 
ney per se makes no symptoms. In some of the cases the general 



382 



DISEASES OF THE URINARY APPARATUS 



Interpretation 
of the symp- 
toms of float- 
ing kidney 



Therapeutic 
indications 



The remedy 
must be me- 
chanical 



Rest and fat- 
tening cure 



Results of rest 
cure 



Pads and 
bandages 



gastro- and enteroptosis may produce a variety of distressing phe- 
nomena that are often, though falsely, attributed to the floating 
kidney. In still other cases, and these form the majority, a 
general neurasthenic state exists, either altogether independent of 
the abdominal conditions or possibly remotely dependent upon the 
digestive disorders and the abnormal traction or pressure on the 
nerve plexuses that the abnormal position of the various abdominal 
viscera, including the kidneys, produces. 

From a therapeutic standpoint slight degrees of floating kid- 
ney are a negligible quantity; whatever treatment may be directed 
towards the general symptoms of the patient should be directed 
more against the abdominal ptosis than against the floating 
kidney as such. Whenever symptoms are produced, however, that 
are directly traceable either to a tugging of the kidney 
on its attachment, or to twisting of the pedicle of the kidney, with 
resulting congestion of the organ and possible hydro-ne- 
phrosis and pain, then special treatment of floating kidney be- 
comes necessary. 

In view of the mechanical conditions existing the remedy 
must needs also be mechanical and directed towards causing a 
restitution of the kidney to its normal position and holding it 
there. Occasionally rest in bed in a recumbent position for weeks 
at a time, especially combined with a Weir Mitchell fattening 
treatment (see index) may lead to an increase of the abdominal 
fat and hence furnish a support for the movable kidney. There 
is no evidence to show that this plan leads to the formation of 
a new fatty capsule around the kidney, nor is there for all that 
any proof that in floating kidney the fatty capsule is lost. The 
plan is particularly useful, however, in thin, neurotic women, both 
because in these cases the increase of the abdominal fat and the 
resulting greater tension of the abdominal walls really supports 
the kidneys in conjunction with the other abdominal viscera, and 
because the rest-cure and the over-feeding act beneficially 
towards restoring nervous equilibrium. The result is that these 
patients frequently arise from the rest and "Mast" cure with a 
kidney that is still somewhat motile but with a nervous system 
whose tone is restored to such an extent that it is no longer 
irritated by the abnormal excursions that the kidney occasionally 
undertakes. 

The use of pads and bandages is rarely of lasting benefit in 
the treatment of floating kidney and is generally disagreeable 
to the patients. If any support is to be applied at all it should 
be a general abdominal supporter intended to hold up all the 
abdominal viscera, possibly with a pad or pelotte, besides, below 
the kidney region. When this is done, the disagreable symptoms 



DISEASES OF THE URINARY APPARATUS 



383 



that are attributed to the floating kidney, but that in reality, -as 
stated above, usually arise from the general abdominal ptosis, are 
frequently relieved. 

Care should always be taken that constipation, over-loading 
of the stomach and congestion of the liver are carefully coun- 
teracted by proper dietetic and medicinal means; for when this is 
done, the weight of the abdominal organs is reduced and less 
dragging permitted. The clothing should properly be worn sus- 
pended from the shoulders and not fastened about the waist. Lacing, 
of course, should be forbidden. 

If the degree of dislocation is so severe that the kidney occasion- 
ally becomes twisted, with resulting hydro-nephrosis and conges- 
tion of the organ with urinary signs that point to degeneration 
and functional disturbances in the renal epithelia, or if the kid- 
ney becomes very sensitive to pressure or hurts spontaneously, then, 
after all the other means have been tried, surgical intervention be- 
comes justifiable; but not before. 

There is unfortunately, nowadays, an exaggerated tendency 
to operate upon the floating kidney in cases of general abdominal 
ptosis; and while the operation rarely does any harm in this 
condition, and may occasionally even do good through the benefits 
derived from enforced post-operative rest in bed and proper feed- 
ing, still, a cure by surgery should never be promised nor the 
operation advised unless symptoms directly attributable to the 
kidney become unbearable, or unless nephritic changes in the dis- 
located organ make their appearance. A description of the opera- 
tive technique lies without the limits of this article. In most 
cases a simple nephrorrhaphy is the operation of choice. 

The acute symptoms produced by twisting of the renal pedicle 
must be relieved by hot applications and morphine, with rest in 
bed, while attempts are made at the same time to correct the 
temporary dislocations of the organ by manipulation, if necessary 
under an anesthetic. 



General ab- 
dominal sup- 
porter 

Constipation 
and gastric 
distension to 
be combated 



The clothing 



Indications for 
surgical treat- 
ment 



Relief of acute 
symptoms 



UREMIA. 



In order to properly treat uremia it is essential to have a clear Critique of 
understanding of the causes that determine pre-uremic states theories uremia 
and the uremic attack, or, as one might also express it, chronic 
and acute uremia. Uremia is commonly considered to be due ex- 
clusively to inadequacy of the renal function, with resulting re- 
tention of excrementitious urinary bodies. If this current be- 
lief were correct, then complete anuria should always pro- 
duce uremia, and the blood of uremic patients should always show 



384 



DISEASES OF THE URINARY APPARATUS 



Anuria does 
not always 
produce uremia 



Uremia and 
urinemia 



Metabolic dis- 
order 



Acidosis 



The kidneys 
not always 
primarily in- 
volved 



The orthodox 
treatment of 
uremia and its 
fallacies 



an increase, and the urine a corresponding decrease, of urinary 
substances. 

As a matter of fact, many cases of complete anuria, due to 
various causes, are recorded, in some instances persisting for sev- 
eral weeks, in which none of the characteristic phenomena of ure- 
mia developed. On the other hand, uremia not unfrequently oc- 
curs when the flow of urine is abundant and the excretion of 
urinary solids and water does not appreciably deviate from the nor- 
mal. Similar results are seen in animals after experimental 
nephrectomy or occlusion of both ureters, or after the injection of 
urine. The animals die, but are not uremic. 

One must, therefore, distinguish, clinically at least, between 
uremia and urinemia. In uremia we witness the signs of urinemia 
but also other signs besides. The latter, precisely, are the most 
characteristic symptoms of uremia and never occur in urinemia. 
This alone forces one to the conclusion that they must be 
produced by other factors than simple urine poisoning, a conten- 
tion that is borne out by an analytical study of the blood and 
urine in uremia. 

Without going into the analytic data in detail the statement 
may be made that quite as many cases of uremia develop without 
as with an abnormal amount of nitrogenous or saline constituents 
in the blood. There also is much chemical and clinical evidence 
to show that in uremia the general metabolism and, in particular, 
the manifold functions of the liver, are perverted. Moreover 
we not infrequently encounter a condition of acidosis that points 
to a severe auto-intoxication that cannot be attributed to renal in- 
adequacy alone.* 

That the kidneys are not always primarily involved is further 
borne out by the clinical observation of an occasional case of 
uremia in which the kidneys are found practically normal after 
death, and in which essentially no evidence of renal disease, or 
even of functional inadequacy on the part of the kidneys, pre- 
sented itself during the life of the patient. 

This newer conception of uremia must induce us to depart 
from the orthodox method of treating uremia. 

We are wont to treat uremia by promoting vicarious elimina- 
tion, i. e., by stimulating the flow of urine, by purging and by 
sweating, with the intention of relieving the kidneys of the 
work of excreting retained urinary bodies. Occasionally we 
even attempt to force these bodies through the damaged kidneys 
by using diuretic drugs. In addition, we try to regulate the 
diet in such a way that there shall accumulate in the blood the 



♦For the details, see Croftan, "An Analytic Study of Uremia.' 
'Jour, A, M. A.," January 6, 1906, 



DISEASES OF THE URINARY APPARATUS 385 

smallest possible amount of residual excrementitious bodies. If, 

now, uremia is not due to the circulation in excess of such bodies, 

nor to renal inadequacy alone, then the above treatment is wrongly 

directed. 

The chief object in chronic uremia, i. e., in pre-uremic states, Prophylaxis of 

uremic attacks 

should be to prevent the development of uremic attacks, i. e., 

of acute uremia, by giving attention to those organs whose func- 
tions threaten to fail; and in order to do this intelligently the 
renal idea should be somewhat relegated to the background and 
more attention should be bestowed upon the liver and the general 
metabolism. 

In chronic uremia the diet should be arranged in such a way The diet in 
that the function of the liver is not overtaxed; at the same time cnromc uremia 
the existence of a chronic nephritis should be included in the cal- 
culation. A diet consisting largely of milk and carbohydrate 
foods is the ideal. In view of the chronic character of the dis- 
order care must, however, above all things, be taken that ade- 
quate nutrition is maintained, and for this reason the addition of Carbohydrates 
some albuminous food, preferably in the form of vegetable albu- 
mens, is very desirable. Carbohydrates possess a high nutritive 
value, and at the same time exercise a gentle stimulating effect 
upon the functions of the liver, without, coincidently, leading to 
the formation of end-products that irritate the kidneys in their 
passage. Alkaline waters are also very useful in this condition, Alkaline wa- 
for they too gently stimulate the liver, and, above all things, Dalies 
counteract the tendency to acidosis which not infrequently ap- 
pears in chronic uremia, as manifested by the increased ammonia, 
excretion in the urine. Calcium carbonate, in fifteen grain doses 
three or four times a day, in powder or capsule, is a useful means to 
aid in maintaining alkalinity. 

The use of hepatic stimulants is also indicated, although great Hepatic stim- 
care should be exercised not to give remedies that can irritate 
rather than stimulate the liver; thus calomel I consider a dan- Calomel 
gerous drug in chronic uremia. Bile acids, preferably in the 
form of sodium glycocholate, in doses of one-fourth to one-half 
grains (0.0015 to 0.003 gm.), together with five to ten grains (0.3 
to 0.6 gm.) of sodium carbonate, half an hour after eating, are 
useful. They possess a distinct cholagogue action and also act as Bile acid salts 
intestinal antiseptics. Salicylates, preferably in the form of salol, Salol 
in one grain (0.006 gm.) doses, together with an alkali, three or 
four times a day, half hour after eating, act similarly and are 
also useful. 

In chronic uremia warm bathing is an excellent preventive Warm bathing 
measure. The patient should be instructed to lie quietly, for five 
or ten minutes, in a tub of water slightly below the body tern- 



386 



DISEASES OF THE URINARY APPARATUS 



Symptomatic 
treatment 



Gastro-intes- 
tinal symptoms 



Heart symp- 
toms 



Cerebro-spinal 
uremia 



Vomiting 



When to 
check vom- 
iting 



Oxalate of 
cerium 



perature, with a cold cloth applied to the head to prevent reactive 
hyperemia of the brain. Such a bath should be given every eve- 
ning and may, to advantage, be followed by an alcohol rub, care 
being taken that the bath-room is warm and the patient does not 
take cold. This measure is very effective in reducing the blood 
pressure and in preventing acute uremia. If threatening cerebral 
signs of uremia appear, a hot bath,, combined with friction of the 
surfaces of the body, is a useful means for aborting convulsions, 
and the patient, in uremic coma, may safely be placed in a hot 
bath while cold water is poured upon the head, provided the other 
means described below for combating acute uremic seizures are in- 
stituted at the same time. 

Chronic uremia principally manifests itself in a protean ar- 
ray of symptoms involving nearly every organ of the body. While 
every endeavor is being put forward to treat the conditions that 
underlie uremia, it becomes necessary in addition to institute 
symptomatic treatment for the relief of disagreeable subjective 
symptoms. In view of the fact that, in uremia, Nature puts 
forward every effort to promote vicarious elimination of accumu- 
lating toxins through the different emunctories of the body, dis- 
agreeable symptoms about these organs, that are due largely to their 
irritation by the poisonous bodies that are clamoring for elimina- 
tion, occasionally require special treatment. Thus vomiting and 
diarrhea are very common symptoms in chronic uremia. In 
addition the heart is very frequently over-stimulated and ul- 
timately becomes fatigued, so that failure of the heart muscle 
makes its appearance with edema and stasis; these phenomena, 
too, occasionally require special treatment. Finally, cerebro-spinal 
uremia, of a chronic type, occasionally appears, presumably due 
either to edema of the central nervous tissues or to irritation of 
these nerve elements by circulating toxins that have a selective affin- 
ity for certain nervous tissues. The symptomatic treat- 
ment of these various uremic phenomena may now be dis- 
cussed seriatim. 

Vomiting in uremia must, as a rule be regarded as an endeavor 
on the part of the organism to rid itself of circulating poisons 
by way of vicarious emesis, and it is questionable whether it is 
good practice to check this vomiting at once. Vomiting may 
occasionally even be stimulated to advantage by giving the patients 
lukewarm water to drink. Only when the vomiting becomes so 
severe that the patients cannot retain any food, or if the heart and 
arteries, and, in particular, the cerebral vessels threaten to be- 
come seriously over-strained, or if the patients cannot sleep, should 
we actively interfere by giving symptomatic relief. For this 
purpose, we can use oxalate of cerium, in doses of from two to ten 



DISEASES OF THE URINARY APPARATUS 387 

grains (0.1 to 0.6 gm.) , frequently repeated. This remedy acts Tincture of 

like bismuth, but is less toxic and frequently stops the nausea 10 ine 

and vomiting. Or the patient may be given from one to three 

drops of the tincture of iodine in ice cold water or in a few ounces 

of cold milk. Chloroform, in doses of from five to ten drops, or Chloroform 

a dilute solution of cocaine as described elsewhere, may also be Cocaine 

given to advantage. If none of these means is efficacious, then 

the swallowing of small pieces of ice and the application of cold Ice 

over the epigastric region may occasionally stop vomiting, and 

sometimes, in extreme cases, lavage of the stomach leads to the Lavage 

goal. 

Uremic diarrhea, which is often troublesome, should always at Diarrhea 
first, be encouraged; that is, a complete evacuation of the gastro- 
intestinal tract should be promoted by the administration of saline 
laxatives, for here we must again assume that the organism is 
trying to get rid of irritating poisons by the bowel path. Saline Saline laxa- 
laxatives are also advantageous in cases of uremia with failing 
heart and venous stasis and edema of the bowel wall, for the 
withdrawal of water from the edematous tissues by the saline acts 
beneficially. If the diarrhea persists so long that the nutri- 
tion of the patient is interfered with, then attempts should be 
made to check the bowel movement by the use of opium or tannin ; Opium 
the former given, preferably, as laudanum, either by mouth, in Tannin 
doses of from five to fifteen drops, repeated every hour or so until 
the desired effect is produced, or by rectum in thirty to sixty 
minim doses, preferably in starch enema and also repeated. Tannin 
is probably best given as tannigen (diacetyltannin), in doses of 
ten to twenty grains (0.6 to 1.3 gm.) repeated until effect. 

The heart is usually seriously affected in uremia, and cardio« Cardio-tonic 
tonic medication, as described in the Chapter on Heart Diseases, 
becomes necessary. Uremic edemas in various parts of the body Edema 
are often due to cardiac failure and they should be treated pri- 
marily by cardio-tonic medication (see index). One of the most 
dangerous forms is edema of the respiratory tract, viz., pulmonary Pulmonary 
edema and edema of the glottis. Here very active measures must 
at once be instituted if the life of the patient is to be saved, and 
energetic sweating and purging becomes necessary, even occasionally 
stimulation of diuresis with the main object in view, irrespective of 
anything else, of ridding the organism as rapidly as possible of 
the accumulated water. Atropine in doses of one one-hun- Atropine 
dredth to one one-hundred-and-fiftieth of a grain hypodermic- 
ally, may be administered if the patient threatens to drown 
in his own secretions. In edema of the glottis, ice applied to 
the neck and ice swallowed are useful. If necessary, scarification 
of the edematous laryngeal folds or even tracheotomy may be 



388 



DISEASES OE THE URINARY APPARATUS 



Uremic asthma 
Ether 



Valerian 
Oxygen 
Chloroform 



Vicarious elim- 
ination 



Stimulation 

salivary 

glands 



Sweating 



of 



Diuresis 



The treatment 
of the acute 
uremic attack 



resorted to. In pulmonary edema cold or mustard plasters to the 
chest also occasionally relieve. 

Uremic asthma is best treated by the use of ether given as 
spirits of ether, in doses of ten to thirty drops several times a 
day; or in the form of pure ether, hypodermically, in doses of 
1 to 2 cc, or by mouth, in teaspoonful doses, three or four times 
during the twenty-four hours. If this treatment, which incident- 
ally stimulates profuse diuresis, does not relieve the asthmatic 
seizure the tincture of valerian, in doses of one to three drachms 
(5 to 10 cc), oxygen inhalation, or a few whiffs of choloroform 
must be tried. 

As stated above it sometimes becomes necessary in chronic 
uremia to stimulate vicarious elimination with the expectation 
that together with much water some toxic material may also be 
eliminated, and in this way a purification of the blood and tissue 
juices be brought about. A very useful measure is to stimulate 
the action of the salivary glands, and a case of chronic uremia 
should be advised to chew gum. For the sake of producing cathar- 
sis, very mild laxatives or dilute laxative water should be used, 
remembering always that no drug that can irritate the liver 
should be used, for this organ, as we indicated above, is commonly 
involved in the chronic uremic self-intoxication. 

Sweating, if advised at all, should always be combined with 
water-drinking or the use of large, water enemas; for unless this 
is done a concentration of the body fluids will be brought about 
and the intoxication be rendered more severe. An acute uremic 
attack, in fact, may be produced by injudicious sweating, particu- 
larly as the blood, when it becomes concentrated by sweating 
without the simultaneous introduction of water, draws abundant 
toxic material from the edematous tissues in which the toxins are 
deposited and carries the poisons in a concentrated form to the 
higher nervous centers. 

Diuresis is best stimulated by digitalis combined to advantage 
with caffein (see formula), by the copious ingestion of hot 
water, preferably slightly alkaline, and by large alkaline, saline 
enemas. 

The treatment of the acute uremic attack is always an un- 
grateful task, for immaterial whether we are dealing with a dis- 
order that is primarily or in its ultimate consequence due to 
renal, hepatic or general metabolic insufficiency, we are in most 
cases concerned with a syndrome that is due to the crumbling of 
the whole cellular edifice. To arrest this collapse essentially 
means to revive a dying organism. That this may occasionally 
be done, for the time being, cannot be denied; and as the re- 
cuperative powers of the human body border on the phenomenal 



DISEASES OF THE URINARY APPARATUS 389 

no effort should be spared to bring an acutely uremic patient back 
to life. 

The acute attack usually sets in with fulminating symptoms 
simulating epileptic seizure (uremic eclampsia) and gradually 
leading to coma, occasionally preceded by a severe headache or a 
syndrome that resembles the aura of epilepsy. 

The appearance of cerebral uremia, manifesting itself by se- 
vere headache, neuralgia, psychic disturbances, insomnia, twitch- 
ings, amaurosis, etc., is usually a grave danger signal, generally 
constitutes a premonitory warning of an impending uremic attack 
and should be fought most energetically. Bleeding is the sovereign Bleeding 
remedy, carried out as described (see index). A considerable 
quantity of blood, if need be a quart, should be withdrawn. A ure- 
mic attack may often be prevented in this way. If large quanti- infusion of 
ties of blood are withdrawn, venesection may be followed to advan- ph Z oi°? « 
tage by the infusion of an amount of warm, sterile, physiological 
salt solution (0.8 gm. to 1,000 cc.) corresponding to the quantity 
of blood abstracted. 

The symptoms about the nervous system unfortunately, as Narcotics 
a rule, cannot be controlled by any other drugs than narcotics, 
i. e., morphine or opium. Occasionally enemata, containing ten Chloral 
to fifteen grains of chloral, repeated every two hours, or inhala- enemas 
tions of chloroform, become necessary. Urethan also is useful here, Urethan 
given by rectum in watery solution in large doses, i. e., about five 
drachms (about 20 gm.) in twenty-four hours. In severe spinal 
manifestations lumbar puncture should be done. It will often be 
found that the fluid in the cerebro-spinal canal stands under high 
pressure, and symptomatic relief is frequently obtained by drawing 
it off, thus reducing this pressure. Lumbar puncture possibly also Lumbar punc- 
relieves by withdrawing fluid that contains much toxic material ture 
in solution from intimate contact with irritable nervous tissues. 



DISEASES OF THE BLADDER AND URETHRA. 

(By Dr. F. Kreissl, Chicago.) 

CYSTITIS. 

In the treatment of cystitis, irrespective of any conventional Definition 
classification, we have to bear in mind that the disease is merely 
a symptom of some underlying pathological lesion ; that every true 
cystitis is of bacterial origin; and that "simple cystitis" is only a 
theoretical condition. 

Since the mode and avenues of infection have become better Prophylaxis 
known, and since it has become established that traumatism and 



390 



DISEASES OF THE URINARY APPARATUS 



Indications for 
treatment 



Rest 

Diet 

Liquids 



Purgation 

Sitz bath 
Fomentations 



Opiates 



infection by instruments is a contributing cause of cystitis, much 
has been accomplished in the way of prophylaxis. This latter 
source of infection (by instruments) can be and is successfully 
eliminated by extreme cleanliness; asepsis and antisepsis in every- 
thing that comes in contact with the urethra; by cleansing the 
latter and the bladder preceding and following the use of instru- 
ments; by preventing stagnation of urine in the bladder; and by 
exercising better care of the urinary tract during labor and avoid- 
ing traumatism during gynecological operations. 

The principal indications for the treatment of cystitis are : 

1. To remove the cause. 

2. To relieve pain and frequent urination. 

3. To modify the character of the urine so as to make it an 
unfavorable medium for the development of pathogenic microbes, 
and 

4. To check suppuration. 

In the acute stage, as in many other local inflammations, rest 
in bed should be insisted upon until the symptoms are well 
under control. The food should be bland and consist largely of 
fluids in small quantities, milk, or milk mixed with Vichy being 
preferable. The still customary ingestion of large quantities of 
fluids in acute cystitis should be discouraged, as it only increases 
the congestion of an inflamed organ, which is much in need of rest. 
Attention should be given to the bowels. A purge of calomel and 
pulverized jalap, 0.3 (grains five) of each, followed by a wine glass- 
ful magnesia citrate, answers the purpose. 

A hot Sitz bath of 105° F., repeated several times daily, if 
necessary, will afford much relief from pain and tenesmus. Hot 
fomentations applied to the perineum and above the pubes are 
almost as efficient; likewise sitting over steaming hot water. In 
addition an anodyne is often necessary to control the vesical tenes- 
mus, pain and irritability. The remedy par excellence is opium and 
its alkaloids. It should be given by mouth or rectum. If given 
by mouth the addition of fol. uvse ursi, or the time-honored linseed 
decoction with salol, will be found serviceable. 



v 



Dose and 
administration 


Decoct, sem. 
ursi), 




Salol, 




Tinct. opii, 




Syr. simp., 




M. 



lini. 



or 



(infus. 



fol. uvae 

150.0 (§v) 

4.0 (gr. lx) 

gtts. xx 

30.0 (§i) 



S. A tablespoonful every two hours. 



DISEASES OF THE URINARY APPARATUS 391 

For suppositories the extract of opium should be combined 
with the extract of belladonna or with morphine: 

Extract opii, 0.18 (gr. iiss) 

Or 

Morphine sulphate, 0.08 (gr. iss) 

(gr. iss) 
Extract of belladonna, 0.06 (gr. i) 

Olei cacao, 6.0 (§iss) 

M. Ft. suppositories No. six. 
S. One suppository twice to three times a day. 

The balsams, oleum santali, fluid extract of pichi pichi, gono- BaSsams 
san (a combination of kava kava and purified sandalwood) and Santal oil 
lately santyl, all have a sedative effect in acute cystitis. The foliae Plchi Pichi 
uvse ursi, the folia buchu and the herba herniariarge are also use- „ . 
ful. They should be taken as infusions, either singly or in mix- Buchu 
ture of equal parts of these herbs, about a heaping tablespoonful Herniaria 
to a large cup of boiling water. Gonosan is nearly free from the 
disagreeable effects of sandalwood oil, and to avoid the unpleas- 
ant eructations should be taken on a full stomach, and very little 
of fluids consumed during or soon after the meal. The dosage is 
two or three capsules (each containing ten minims) three times 
daily. It is especially efficient in gonorrheal cystitis. So is santyl 
in the same dose. Santyl on account of being almost tasteless may 
also be prescribed in the following way : 

Oil santyl, 15.00 (gss) 

Pulv. gum tragacanth, 7.50 (3ii) 

Syrup simple, 45.00 (§ss) 

Aqua, q. s., 120.0 (giv) 

M. 

S. Teaspoonful three times daily. 

(Each Si represents 1% drops oil santyl.) 

Sometimes it will be necessary to give internal antiseptics in Urinary 
order to attack the root of the evil. The most commonly em- antiseptics 
ployed remedies of this class are salol, camphoric acid, boric acid, 
benzoic acid and last, but not least, urotropin. Salol may be given galol 
in doses of 0.5 to 1.0 gm. (7 to 15 grains) three times daily. Be- 
ing a phenol derivative it should not be prescribed where kidney le- 
sions exist. 

A combination of the antiseptic and astringent qualities oc- 
curs in the following formula: 



392 



DISEASES OF THE URINARY APPARATUS 



Boric acid 



Camphoric acid 
Benzoic acid 



Urotropin 



Dose and 

administration 



Toxic 
symptoms 



Local 
treatment 



Instillations 



9 

Salol, 

Extract of uva ursi sice, aa 5.0 ( & iv) 

M. Ft. pill No. XXX. 

S. Two to three pills three times daily. 

Boric acid, to be effective, should be taken in doses of 0.5 to 
1.0 gm. (7y 2 to 15 grains), several times a day, but occasionally, 
it must be remembered, this may cause toxic symptoms such as 
exanthema, albuminuria and extreme weakness. 

The dosage of camphoric acid is 1.0 gm. (15 grains) three 
limes a day; of benzoic acid 0.3 to 0.5 (4% to l 7 1 / 2 grains) three 
lames a day. Both have a marked deodorizing effect on ammoniacal 
urine, but distress the stomach if given for a long time. 

In urotropin we possess the strongest urinary antiseptic of 
more recent date. However, it does not seem to have any effect 
on the gonococcus or the bacillus tuberculosis. It requires an acid 
urine in the renal pelvis in order to develop its active principle, 
formaldehyde, but the latter, after being once liberated, acts alike 
in acid or alkaline urine. In the cystitis of typhoid fever, it is, 
so to say, a specific. It is given in doses of 0.3 to 0.5 gm. (4^2 
to 7% grains) twice to three times daily and should always be 
dissolved in a few ounces of water. It may be used for weeks 
arid even months without any ill effects. Occasionally its adminis- 
tration may be attended by toxic symptoms, which are compara- 
tively frequent when the drug is not properly diluted. The de- 
velopment and the degree of the toxic effect is not always correl- 
ative with the size of the dose. Among the toxic symptoms may 
be noted irritation of the stomach, diarrhea, abdominal pain, ex- 
anthema, ringing in the ears, albuminuria, hematuria and stran- 
guary — the latter the result of contact with raw surfaces (ulcera- 
tions). These symptoms subside readily with the discontinuance 
of the drug. 

After the acute symptoms of cystitis have subsided — usually 
within a few days — local treatment of the bladder frequently be- 
comes necessary to remove the cause of the trouble or to cure a 
lingering congestion of the mucosa. Here either an exacerbation 
of a chronic cystitis, tuberculosis, gonorrhea, or ulcer of the blad- 
der call for topical applications, which may be either antiseptic or 
astringent, oftentimes combining both qualities, or anodynes com- 
bined with antiseptics. These medicaments are employed as in- 
stillations or injections. In the subacute stage only instillations 
are advisable and only soft instruments of small caliber should be 
introduced. The most suitable instruments are a graduated syringe 
holding four cc. (one drachm), and a gum elastic capillary bougie 



Iodoform 
Guaiacol 



DISEASES OF THE URINARY APPARATUS 393 

(Guyon's instillator) . Owing to the intolerance of the inflamed 
bladder wall to tension, only small quantities can be used, and the 
medicinal solution should be applied drop by drop. The small- 
ness of the quantity permits a stronger concentration than could 
be used in the form of an injection without being followed by 
severe irritation, and this circumstance makes the method so much 
more efficient. 

Most commonly employed for instillations, and very efficient, Silver nitrate 
are one-half to five per cent, solutions of silver nitrate ; 1 in 3,000 Bichloride 
to 1 in 500 solutions of bichloride of mercury; ten to twenty per Gomenol 
cent, gomenol oil and one to ten per cent, suspensions of iodoform. 
The latter also combined with guaiacol in the formula of Pirot : 

Iodoform, 1.0 (gr. xv) 

Guaiacol, 5.0 ( 9 iv ) 

Oleum benne steril, 100.0 (giii ) 

M. 
4 cc. (one drachm) of this suspension, once daily may be used. 

Of the silver nitrate and bichloride of mercury solutions, it is Quantity and 
the rule to decrease the quantity and increase the intervals between instillations 
instillations with the concentration of the solutions. For instance, 
an instillation with a 1 per cent, silver nitrate, or a 1:5,000 bichlo- 
ride solution should not exceed two cc. (% drachm), and may be 
given once daily, while a two per cent, silver nitrate, or a 1 :3,000 
bichloride, solution should not exceed one cc. (^ drachm) and 
may be given once every other day. Not more than six drops of 
a three to five per cent, silver nitrate, or a 1 : 2,000 to 1 : 1,000 bichlo- 
ride of mercury, solution should be used, and these not oftener 
than once in three to five days. 

Silver nitrate is most valuable in the treatment of cystitis and, 
so to speak, may be regarded as a specific in gonorrheal cystitis. 

Bichloride of mercury is more effective in cystitis caused by a 
mixed infection. 

In subacute cystitis, argyrol in ten to twenty-five per cent. Argyrol 
solutions may be used for a while, when the bladder is still intol- 
erant to silver nitrate; its qualities as a gonocide, however, are in- 
ferior. Stronger in this respect than argyrol, and yet much less 
irritating than silver nitrate, is nitric acid, in one-half to one Nitric acid 
per cent, solutions. A five per cent, gomenol mixture is also very 
beneficial in this stage. 

In the more chronic stage, irrigations of the viscus become Irrigations 
necessary, when the viscid pus or mineral deposits clinging to the 
bladder wall call for a thorough cleansing preceding other topical 
applications. But even then one should never inject more than 



394 



DISEASES OF THE URINARY APPARATUS 



Chin os ol 
Pyoktanin 



Salicylic acid 

Boric acid 
Acetate of lead 

Alcohol 



Bichloride 
Silver nitrate 
Nitric acid 



Collargol 



two ounces at a time, because the bladder muscle reacts differently 
toward slow and rapid tension, a fact of which one may convince 
himself by rapidly filling a normal bladder with ten ounces of 
fluid. There will be tenesmus for quite a while afterward while 
the same bladder does not take notice of such a quantity if accu- 
mulated in the natural way and time. The result of such rapid 
filling of a diseased bladder is seen in renewed congestion and se- 
cretion, and many times a protracted cystitis is due to this proced- 
ure. Moreover, the cleaning of the bladder wall is much more 
thoroughly accomplished by small and repeated flushings than by 
a few large ones. For all these reasons a sterile piston syringe is 
preferable to the much employed irrigation can. 

Chinosol and pyoktanin in a solution of 1 :4,000 have a marked 
deodorizing effect on very offensively ammoniacal urine. Four cc. 
(one drachm) of a five per cent, iodoform suspension most effec- 
tively checks ammoniacal decomposition of the urine, but the 
strong odor of the remedy prevents its general adoption outside 
of a hospital. Salicylic acid in a concentration of 1 :3,000 dis- 
solves phosphatic debris and renders an alkaline urine neutral or 
slightly acid. A saturated solution of boric acid, or a solution of 
1 :3,000 of acetate of lead, has a soothing effect in simple con- 
gestion of the mucosa associated with a mucous secretion, but it is 
of little antiseptic value. Alcohol combines antiseptic, astringent 
and deodorizing properties, and if properly diluted with water it 
is free from irritation. The strength of the solution at first should 
be three per cent., gradually increasing it until it reaches ten per 
cent. Not more than 300 cc. (ten ounces) should be used in one 
treatment, and the last 30 cc. (one ounce) of the solution may be 
left in the bladder. 

Bichloride of mercury solutions should be injected in concen- 
trations from 1:5,000 down to 1:20,000; silver nitrate from 1:10,- 
000 to 1 :1,000 ; and nitric acid from 1 :6,000 to 1 in 3,000. From 
250 cc. (eight ounces) to 1,000 cc. (one quart) of the liquid may 
be used at one treatment in the manner described before, and re- 
garding quantity and intervals one should be guided by the same 
principles as stated for instillations. If the injections are fol- 
lowed by much tenesmus, flushing with a warm normal salt solu- 
tion gives immediate relief. 

The antiseptic and non-irritating qualities of collargol (colloidal 
silver) suggests its employment in cystitis. After cleansing the 
bladder with warm water, 50 to 100 cc. (one and a half to three 
ounces) of a one to two per cent, solution of collargol may be in- 
jected and retained even for hours. 

Every topical application should be made to an empty bladder. 
Silver nitrate and bichloride of mercury precipitate albumen, and 



DISEASES OF THE URINARY APPARATUS 395 

it is, therefore, necessary to clean the viscus thoroughly with sterile 
water preceding every such application. 

Silver nitrate is contraindicated in tuberculosis of the bladder, 
in multiple or extensive ulcerations, and in a contracted bladder. 

In urethro-cystitis in the male the posterior urethra is included Urethro-cystitis 
in the treatment in the following manner : 

In the subacute type. After having deposited the required 
quantity of the medicated solution in the bladder, the tip of the 
capillary catheter is to be withdrawn for about one inch (which 
brings it to the center of the deep urethra), then two to four cc. 
(y 2 to 1 drachm) of the same solution are injected and the in- 
strument removed. 

In the chronic type. A silkweb or Nelaton catheter is passed 
into the bladder, the latter emptied, and the medicinal fluid in- 
jected. The catheter is then withdrawn until no fluid from the 
bladder escapes through it. This indicates that the eye of the 
catheter has left the bladder and rests in the deep urethra just be- 
low the internal sphincter. Fluid injected now escapes from the 
eye of the catheter into the deep urethra and towards the external 
sphincter (compressor urethrae). This striated muscle closes tight- 
ly around the catheter, preventing the downward flow of the fluid, 
which then runs upward and backward into the bladder unchecked 
by the less resistant vesical sphincter (a non-striated muscle). 
The desired quantity having been injected, the catheter is again 
introduced into the bladder and the latter emptied. 

This procedure may be repeated until the bladder is filled for 
the last time, whereupon the catheter is withdrawn and the patient 
allowed to empty his bladder. 

If performed for mechanical cleansing the injection should be 
repeated until the fluid returns clear. 

The frequency of injections depends on the severity of the Frequency of 
symptoms, on the quantity of pus secreted, the rapidity of its re- rea men 
accumulation, and on the degree of infection. Sometimes two in- 
jections a day are required, sometimes one, and in very mild cases 
perhaps but one every other day. 

The complete contraction of a bladder which has been over-dis- Procedure in 
tended for a time, or which is very sensitive, causes much pain, and bLa.dder S Cn C 
the method of injecting then has to be modified. The bladder is 
not completely emptied, but a small amount of urine is left and not 
more than sixty cc. (two ounces) of the medicinal fluid injected. 
The same quantity is withdrawn and again sixty cc. of fluid in- 
jected, and this procedure repeated over again until the fluid returns 
clear. In this way the cleaning of the bladder is gradually accom- 
plished without any discomfort or pain. 



396 



DISEASES OF THE URINARY APPARATUS 



Continuous 
catheter 



In other forms of chronic cystitis complicated by urine retention 
and fever the injections, even when repeated several times daily, do 
not improve the local and general condition sufficiently. In these 
cases it is imperative to prevent the accumulation of even the 
smallest quantities of urine, for a while to exclude the bladder from 
its function as a reservoir. Injections through the continuous 
catheter (Pezzer or Malecot) serve this purpose admirably. Yery 
soon the urine clears up, the fever subsides and pain and tenesmus 
disappear. 

If with all these procedures no marked improvement becomes 
noticeable within a reasonable time, one has to resort to cystoscopy 
to determine the real condition back of a symptomatic cystitis which 
is not amenable to radical cure unless the original cause is removed. 

Stones will have to be crushed or removed by lithotomy. Ulcer- 
ations must be curetted and cauterized through the operation cysto- 
scopy or excised through a suprapubic or a vaginal opening, as the 
case may require, and a rebellious cystitis dolorosa, where the whole 
bladder wall represents a large sloughing ulcer, requires broad in- 
cision and drainage, like any other abscess. Topical applications 
and internal medication will fail when strictures, prostatic ob- 
struction or a diverticle cause the formation of a pool of stagnating 
residual urine in the bladder which forms an excellent culture me- 
dium for microbes. 

It is, of course, also impossible to restore normal conditions of 
the bladder wall if a continuous or interrupted stream of pus from 
adjacent organs, or from the upper or lower urinary passages, floods 
the vesical cavity. Neither will local treatment in secondary tuber- 
culous cystitis be efficient, unless we support the reconstructive 
power of the tissues by a general hygienic treatment of the system, 
or by the removal of the primary seat of the trouble. 



ACUTE URETHRITIS. 



Non-infectious 
urethritis 



The treatment of urethritis depends upon its etiology. 

I. The discharges of a non-infectious urethritis, as observed 
under various etiological conditions, show a marked tendency to a 
rapid cure, if the cause is recognized and suitable treatment insti- 
tuted. A urethral secretion following a traumatism, such as from 
the use of instruments, the presence of foreign bodies, a new-growth 
in the canal, masturbation or excessive coitus, will spontaneously 
disappear when the cause of the trouble ceases to exist. This re- 
sult will also occur in discharges due to chemical irritations, such 
as strong injections with bichloride of mercury or silver solutions, 
which are frequently used as a proplrylactic after cohabitation. 



urethritis 



DISEASES OF THE URINARY APPARATUS 397 

To allay the irritation an urethral injection with the following 
solution is serviceable: 

Extract hydrastic fl. (Lloyd), 30. grm. (gi ) 

Aquae, 150. grm. (§v) 

M. 

S. Inject 3 to 4 times a day. 

Urethral secretions appearing as a part of the symptoms of 
general conditions such as gout, constipation, phosphaturia and 
oxaluria, will yield to the proper constitutional treatment of these 
ailments. 

II. The four principal types of infectious urethritis are, in the Infectious 
succession of their frequency, as follows : 

1. Gonorrheal urethritis. 

2. Infectious urethritis of non-gonorrheal origin. 

3. Syphilitic urethritis. 

4. Urethritis tuberculosa. 



GONORRHEAL URETHRITIS. 

In a two percent, nitrate of silver solution, or in a four per 
cent, protargol solution, we possess an efficient preventive. To this 
end a few drops of either solution may be applied with a syringe 
or a glass dropper in the fossa navicular! s and there retained for 
a few minutes, shortly after a suspicious cohabitation. 

The abortive treatment may be tried in every case of urethritis Abortive treat- 
which is not older than two days. While, of course, the best re- 
sults may be expected on the first day of the manifestation of the 
disease, there are sufficient proofs that the gonococcus does not al- 
ways penetrate so rapidly into the tissues as to escape the influence 
of the germicide even after a few days ; and so long as no harm can 
be done by this treatment, if judiciously applied, it is worth while 
to attempt an abortive cure within the above time limit. 

After irrigating the anterior urethra with a hot boric acid so- 
lution a constricting rubber band should be placed around the penis 
at the penoscrotal junction, and one drachm of a four per cent, 
protargol solution injected and retained for five minutes. For ir- 
rigation with the boric acid solution a piston syringe and a sterile 
elastic catheter should be used. No pressure to distend the urethra 
should be applied and the fluid should commence flowing through 
the catheter before it enters the urethra, whereby the dissemination 
of infectious material is avoided. 



ment 



398 



DISEASES OF THE URINARY APPARATUS 



Avoidance of 
alcoholic and 
sexual excite- 
ment 



Diet 



Suspensory 



Precautions to 
prevent autoin- 
fection and in- 
fection of 
others 



Necessity of 
early treatment 



During the following eight days the anterior urethra should 
be irrigated in the same manner with, a pint of a 1 : 3,0 00 hot ni- 
trate of silver solution, once a day. The discharge, if there be any, 
is examined miscroscopically every day. If no gonococcus be pres- 
ent in the last five specimens, the treatment may then be discon- 
tinued ; otherwise, the systematic treatment for gonorrheal urethritis 
should be commenced. 

The use of alcoholic beverages should be absolutely prohibited 
except in patients in whom, from long continued habituation, grave 
nervous disturbances would likely follow its sudden withdrawal. In 
these cases some claret diluted with water may be allowed. 

Sexual excitement and physical exertion must be rigorously 
avoided. 

The diet should be non-stimulating. Meats in excess, highly- 
seasoned foods, strong tea or coffee are to be avoided in the acute 
stage. 

A well-fitting suspensory bag will relieve the sensation of drag- 
ging on the spermatic cord when the patient has to be much on his 
feet. A piece of antiseptic gauze, not cotton, to catch the discharge 
should be placed around the glans penis in such a way as not to 
constrict the urethra. Most convenient for this purpose are the 
little bags called "gonorrhea bags." Patients having a roomy pre- 
puce may use a dressing consisting of a few layers of gauze four 
inches square with a slit cut in the center just large enough to be 
pulled over the glans into the coronary sulcus. The prepuce is 
then drawn forward over the gauze and glans. 

For women, a gauze sponge saturated with an antiseptic should 
be placed between the labia and renewed after each micturition. 
Male patients must also be advised of the necessity of renewing 
the gonorrhea bags, if such be used, as soon as they become 
soiled, which should rarely occur if the gauze is properly, and of 
necessary thickness, wrapped around the penis. 

Every patient should be clearly apprised of the danger of com- 
municating the disease not only to other persons but also to other 
parts of his own body, especially the eyes, and the rectum ; and the 
necessary instructions should be given how to prevent this. 

Undoubtedly gonorrheal urethritis in exceptional cases has 
disappeared without any treatment, or notwithstanding an internal 
medication. It must also be admitted that a gonorrheal urethritis 
will occasionally terminate favorably by prolonged rest in bed, 
together with a milk diet and urethral injections of plain hot water. 

But against these sporadic facts I submit the numerous cases 
which run a troublesome if not disastrous course if unattended to or 
not properly treated from the beginning. And then again nobody 
would seriously think of keeping a large proportion of our male 



DISEASES OF THE URINARY APPARATUS 399 

population in bed for weeks at a time on account of gonorrheal 
urethritis, when by suitable treatment the patient can be cured in 
a manner which does not necessitate detention from his daily pur- 
suits nor the invention of a pretext for remaining in seclusion. 

In order to deal successfully with acute gonorrheal urethritis the Points of im- 
f ollowing points should be distinctly remembered : successful treat- 

1. The acute symptoms are due to the irritating qualities of ment 
the toxins. 

2. The tissues if slightly assisted are usually capable of taking 
care of the gonococcus, consequently the toxins will have to be 
frequently removed and the gonococcus, as far as it can be reached, 
destroyed. 

3. The treatment should be commenced as early as possible 
after the infection and remedies selected which, while possessing 
strong germicidal qualities, do not increase the inflammatory con- 
ditions already present. 

Injections and not irrigations under pressure should be em- Local treatment 
ployed and even Janet, the sponsor for the irrigation method for 
acute gonorrheal urethritis, has come to this point of view, as ex- 
pressed by the author some years ago. The effect produced by 
these irrigations is just contrary to the principles so essential in 
the management of the acute stage of gonorrheal urethritis. The 
poor results, the almost inevitable complications and chronicity Irrigation treat- 
of such cases, is not so much surprising as the tenacity with which ^ nei Ju harm J ul 
some physicians still adhere to this method. Potassium perman- stage 
ganate, even in the strength of 1 in 500, has no effect on the gono- 
coccus. The only benefit that could possibly be obtained (the 
cleansing of the urethra by large quantities of warm fluid), is off- 
set by the irritating mechanical and chemical qualitites inseparable 
from this method. A diuretic serves the same purpose in a per- 
fectly harmless way. 

The syringe should have a capacity of three drachms, should 
have a blunt tip and may be made of glass, rubber or metal, so 
that it can be thoroughly cleansed and sterilized. The quantity 
to be injected at a time depends on the capacity of the anterior 
urethra ; however, enough fluid should be used to slightly balloonise 
the canal without any perceptible discomfort to the patient. It 
should also be borne in mind that the capacity of the urethra varies 
with the degree of inflammation. 

The patient should be instructed in the proper manner of in- Mode of in- 
jecting. This remark might be considered unimportant, but experi- J ectin S 
ence in this respect has demonstrated the necessity of doing so in 
every case. Some patients, if not instructed, inject in such a way 
that most of the solution runs out alongside the syringe before it 
even enters the urethra ; others inject properly, but lose the greater 



4U0 



DISEASES OF THE URINARY APPARATUS 



part of the solution by insufficient pressure with the fingers at the 
meatus. I have known patients to inject into the preputial sack, 
and one whho squirted the medicine onto the glans penis. 
Protargol The remedy which has given the most satisfactory results for 

many years, and which now seems to be generally recognized as the 
most valuable, is protargol. If judiciously used, it promptly 
destroys the gonococci, where they can be reached ; it rapidly allays 
inflammation, and surely prevents complications. 

The strength of the solution, the frequency of the injection and 
the length of time it should be retained all depend on the stage of 
the disease. Generally speaking, I would say that in the acute stage 
with much inflammation the solution must be very dilute; it 
should be injected at short intervals and retained but a minute. 
With the acute symptoms subsiding the strength may be increased, 
the frequency of the injections reduced and the solution retained 
for a longer period. 

Proportionately with the concentration and the time the pro- 
targol solution is retained a more copious reactive secretion is ob- 
served at least for a few days. This is particularly noticeable upon 
arising and should be explained to the patient beforehand, lest 
he be unnecessarily alarmed. 

As a routine method of treatment for this class of cases the 
following procedure may be recommended: 

The patient should urinate before each injection so as to me- 
chanically remove the secretion from the urethral wall. He should 
then inject a one-eighth per cent, solution of protargol and retain 
it for one minute, repeating the treatment every two hours during 
the day and twice during the night. The latter point is of the ut- 
most importance for a speedy and safe cure, and many complica- 
tions and chronic cases are due to the neglect of this principle, 
advanced by the author and which he has tried to impress upon the 
practitioner for years. 

After three days a one-fourth per cent, solution should be in- 
jected every three hours during the day and once during the night. 
At the end of the first week the strength may be increased to one- 
half per cent., to be injected every four hours and retained for five 
minutes, while the night injection may be discontinued. At the 
beginning of the third week the same solution may be injected three 
times a day and retained for five minutes at a time. At the be- 
week ginning of the fourth week, when the secretion will be found to 
contain mostly epithelial cells, no, or but a few, leucocytes, and no 
gonococci, an astringent and mild antiseptic may be substituted for 
the morning and noon injection with protargol, but the latter should 
still be used before retiring. 



Importance of 
night injections 
in the actue 
stage 



First 
Fourth 



to 



DISEASES OF THE URINARY APPARATUS 401 

The astringents most employed and serviceable are: Astringents 

Zinc sulphorcarbol., 0.60 (gr. ix) 

Resorcin, 1.80 (gr. xxviii) 

Aqua destil., 140.00 (gv) 

Fluid extract Hydrastis (Lloyd), 40.00 (3x) 
M. Sig. Inject morning and noon. 

Zinc sulph., 1.0 (gr. xv) 

Plumb, acet., 2.0 (gr. xxx) 

Aqua destil., 200.0 (gvii) 

M. (This is known as Kicord's formula.) 



Cupr. sulph.,, 
Alum, crud., 


0.20 (gr. iii) 
1.00 (gr. xv) 


Aqua destil., 
M. Sig. 


200.00 (SJvii) 


9 

Crurin, 

Aq. destil., 

Glycerin, 

Aq. destill, q. s., 

M. 


1.0 (gr. xv) 

aa 5.0 (gr. lxxv) 
200.0 (gvii) 



The astringents should be retained for a minute at a time. Preparation of 

Fresh solutions of protargol, not older than three or four days, protargol 
should be used, and they should, therefore, not be made from stock 
solutions and must be kept in stained-glass bottles. They should 
be prepared slowly by spreading the powder on the surface of 
cold water and not by mixing, stirring, heating or by the addition 
of solvents. These small details seem to be overlooked quite fre- 
quently but are important. 

Argyrol may also be used in the acute stage of gonorrhea. Argyrol 
In order to be efficient the strength of the solutions must be ten 
per cent, to twenty-five per cent. In such concentrations the rem- 
edy, on account of its high price, is not within reach of patients in 
moderate financial circumstances. 

The female urethra is not suitable for injections, nor is it Female 
possible to retain fluids therein for any length of time. Therefore, gonorrhea 
instead of these the author always successfully employs urethral 
bougies one inch long, made of protargol and gelatin. They Urethral 
should be inserted in the urethra once, and, later on, twice a day bougies 
and there retained for ten to fifteen minutes by a pledget of gauze or 



402 



DISEASES OF THE URINARY APPARATUS 



Vaginal 
douches 



Silver nitrate in 
stubborn cases 



Complications 

Rest 

Diet 



Balsams in 
acute posterior 
urethritis 



Deep injections 
with protargol 
or argyrol 



cotton lightly held against the urethral orifice. By squeezing the 
bougie for an eighth of an inch upward from the orifice no artificial 
retention at all, in the recumbent position, is necessary. After the 
gonococcus has disappeared from the discharge, astringent medi- 
cated bougies may be inserted on alternating days with protargol 
bougies for about two weeks and, finally, the astringent alone for 
another week. Precautionary hot vaginal douches with a quart of 
a 1 in 3,000 protargol solution, or 1 in 10,000 silver nitrate, twice, 
and, later, once a day, should be used. The vestibulum, the area 
around the vulvo-vaginal glands, the urethra and the clitoris should 
also be cared for in the same manner. Most effective for this pur- 
pose and easily retained is a gauze sponge saturated with the pro- 
targol solution and placed in the vestibulum. It should be replaced 
by a fresh one after each micturition. 

Occasionally, but rarely, if the gonococcus lingers in the urethra, 
it will be necessary to employ protargol solutions as strong as one 
per cent.; they may not be used more than once a day and, if 
found inadequate, a 1 in 2,000 silver nitrate solution, injected 
twice a day, may be substituted with satisfactory results. Before 
injecting silver nitrate solutions the urethra must be cleansed with 
warm water in order to prevent precipitation. Where this fails, 
after it has been tried for a reasonable time, closer investigation 
will reveal some complication, the most common being stricture, 
infection of a paraurethral duct, a periurethral or a follicular ab- 
scess, invasion of the Cowper glands, or the disease has crossed 
the external sphincter and invaded the posterior urethra with or 
without producing acute inflammatory symptoms. Constitutional 
diseases are likely to prolong the urethritis and favor complications 
and should therefore be attended to. 

Complications. — Acute posterior urethritis, which is character- 
ized by symptoms identical with those of acute cystitis, requires 
rest in bed for a few days, a strict milk diet, care of the bowels, in 
short, the same mangement as acute cystitis. The medication in- 
dicated for acute cystitis should be instituted and injections in the 
anterior urethra should be discontinued until the very acute symp- 
toms have subsided. Gonosan, in these cases, has not the least spe- 
cific effect on the gonococcus, as is claimed for it, but it renders the 
urine bland and helps to allay the inflammatory symptoms. Santyl, 
which does not cause gastritis or dermatitis, and does not irritate 
the kidney, is preferable. The dose is from two to four capsules, 
three times daily. With improvement of the acute symptoms the 
injections may be resumed, and local treatment of the deep urethra 
and the vesical neck added. Daily deep injections with a drachm 
of a twenty per cent, argyrol solution and later of a one-half 
per cent protargol solution will answer the purpose. These are 



DISEASES OF THE URINARY APPARATUS 403 

given like bladder instillations (see section on Cystitis), with the 
difference that the tip of the capillary catheter is placed in the 
vesical neck and the solution then deposited, drop by drop, over 
the whole inflamed area while the catheter is being slowly with- 
drawn to the external sphincter. 

If not recognized or taken in hand in time, posterior urethritis 
involves the prostate parenchyma, causing prostatitis. This is most 
likely to occur when the posterior urethra becomes infected with- 
out causing acute symptoms, which latter would draw attention to 
this complication. In order to timely recognize this subacute type Subacute type 
of posterior urethritis the two-glass test as described in the section 
on Chronic Urethritis should be frequently employed in an unduly 
prolonged case of acute gonorrhea. 



PROSTATITIS. 

This complication of acute gonorrheal urethritis requires, be- 
sides the treatment for acute posterior urethritis, applications of 
cold to the posterior aspect of the prostate in order to prevent sup- 
puration. This is best accomplished through the rectophore ap- Rectophore 
plied for fifteen to thirty minutes, several times daily. The tem- 
perature of the water circulating through the apparatus should 
not be so low as to produce discomfort. Ice-bags applied to the Ice bags 
perineum add to the comfort of the patient; some, however, ex- 
perience more benefit from heat. 

Eetention of urine, as it occurs in some of these cases, may be Urine retention 
relieved by catheterizing under the necessary antiseptic precautions. Catheterization 
Only soft rubber catheters are permissible for this purpose, and 
the bladder irrigated with a mild antiseptic solution after the 
urine has been drawn. 

If, in spite of the antiphlogistic treatment, pus forms and a Prostatic 
prostatic abscess can be palpated through the rectum, it should 
be evacuated by a perineal incision. The method of opening the 
abscess through the rectum has been abandoned and is only per- 
missible where an abscess is just ready to break through the dividing 
tissues into the rectum. The danger of gonorrheal prostatitis and 
the risk of causing troublesome urethro-rectal fistula is too great to 
practise the last named procedure as a routine method. 

The position of the patient and the first steps of the operation Surgical relief 
are the same as in perineal prostatectomy. After the rectum has 
been liberated and dragged downward and the prostate exposed, 
the abscess is punctured and the opening bluntly enlarged with the 
arms of a dressing forceps, or an artery clamp. A drainage tube 
is then inserted; the abscess cavity irrigated; the wound loosely 



404 



DISEASES OE THE URINARY APPARATUS 



Spontaneous 
rupture of 
abscess 



packed with iodoform or vioform gauze and partly sutured. Heal- 
ing takes place within three to four weeks. 

If there are clinical symptoms of abscess formation without 
the palpable evidence of fluctuation on the rectal aspect, surgical 
steps may be delayed for a few days. Frequently one or more 
abscesses may have a tendency to rupture into the urethra. Should 
this happen it is followed by remission of all distressing symp- 
toms and the appearance of much pus in the urine. If spontane- 
ous rupture does not take place very soon, the puncture of the 
prostate through the rectum and aspiration for diagnostic pur- 
poses is permissible. When pus is found in this manner it should 
then be evacuated by a perineal incision. If not surgically relieved 
within proper time much of the prostatic parenchyma becomes 
destroyed, or the pus breaks through the capsule and burrows its 
way beyond control. Some cases of this kind have terminated 
fatally by phlebitis and phlebothrombosis. Even if not leading 
to such serious complications, chronic prostatitis is bound to follow 
delay. 



EPIDIDYMITIS. 



Rest 
Heat 



Guaiacol 
applications 



Combined ef- 
fect of guaiacol, 
heat and sus- 
pension 



The indications for the treatment of this condition are: 

1. To relieve the pain and inflammation, and 

2. To promote the absorption of the inflammatory products. 
The first purpose is best accomplished by rest in bed, a suitable 

support for the testicle and the application of heat in the form of 
hot fomentations or a hot poultice. If taken in hand before the 
acute symptoms have reached a climax, the following procedure 
usually gives satisfaction : Apply with a brush or a gauze sponge 
a solution of equal parts of guaiacol and glycerin all over the 
scrotum of the afflicted side; this causes considerable smarting for 
several minutes. The whole scrotum should then be wrapped in a 
square of absorbent cotton, twelve by twelve inches, and one inch 
thick. This may be covered with a piece of oil-silk or rubber pro- 
tective tissue of the same size and the whole held in place by a 
large suspensory bag. The bag for this purpose must be extra 
large to accommodate the voluminous mass to be placed therein, 
and should have a strong elastic abdominal band, the latter to be 
adjusted so as to suspend the testicle as high as possible. The 
guaiacol acts as an antiphlogistic and anodyne; the cotton, cov- 
ered with oil-silk, as a dry poultice; and the suspensory, if prop- 
erly adjusted, takes away all the dragging of the testicle on the 
tender, inflamed cord. The effect* is a momentous one; patients 
whose features were distorted with pain are able to walk briskly 
immediately after the testicle is immobilized in the manner de- 



DISEASES OF THE URINARY APPARATUS 405 

scribed. One application of the guaiacol is sufficient, but the cot- 
ton, being worn down, should be removed at least once in twenty- 
four hours. 

Three grains of salicylic acid, with lemonade, taken twice daily, Internal medi- 
seem to assist in the acute stage. Within five to eight days the ca lon 
swelling of the epididymis is usually reduced by one-half, and the 
greater part of the inflammatory effusion in the albugineal sac- 
will have become absorbed. 

Moist heat furthers the resolution of the nodules at this stage. Absorbent 
Eight thicknesses of a piece of moist gauze, ten by ten inches, are 
wrapped around the whole scrotum; this is covered with oil-silk 
of the same size; over this is placed a layer of cotton, twelve by 
twelve inches and a half inch thick, and the whole is supported 
in the suspensory bag, to be renewed mornings and evenings. 
Unguentum Crede, or a ten per cent, ichthyol ointment may be 
substituted for the moist gauze during the day, the latter being 
reserved for the night dressing. 

In a few cases the very abundant effusion in the albugineal sac Scarification 
causes so much tension that absorption becomes impossible. In this a PP in S 

event VidaFs multiple scarifications, or tapping of the tunica vag- 
inalis, will be necessary to open an avenue for the escape of some 
of the fluid. In some instances abscess formation in the epididymis 
occurs, necessitating free incision of the albugineal sac and evacua- Abscess 
tion of the pus, which is usually found in the head of the epididy- 
mis. This course will give speedy relief. 

Somnoform as a general anesthetic is serviceable for this short 
operation, but four to five ctgr. of a one per cent, stovain solution, 
locally injected, is just as efficient. 

The pus obtained ought to be examined, as occasionally tuber- 
culosis causes the suppuration. 

Cases of rebellious epididymitis, which do not yield to the Latent tuber- 
usual methods of treatment, or which are subject to frequent recur- culosis 
rence, should be operated in the manner devised by Bazet, viz. : 

"An incision is made in the globus minor near its attachment Rebellious 
to the testicle. At this point there is no danger of wounding the epl l y mitis 
testicle or opening the vaginalis. Seizing firmly the swollen nodule 
of the globus minor in the left hand an incision one inch long is 
made downwards into the cavity of the epididymis, the pus evac- 
uated, and the walls of the epididymis sutured to the skin. The 
wound is packed with gauze impregnated with one-tenth ichthyol 
and glycerin, a dressing applied and the organ well supported. The 
wound heals in a week. The patient is able to be up in four to 
seven days." 

If left to themselves these small abscesses lead to very stubborn 
fistulse which are likely to eventually destroy the epididymis. 



406 



DISEASES OF THE URINARY APPARATUS 



Balsams 
ful 



harm- 



Injections dur- 
ing epididymitis 



Malarial 
epididymitis 



During an acute attack of epididymitis no balsams of any kind 
should be given internally. Many a case of persistent inflamma- 
tion readily disappears when this point is observed. I do not be- 
lieve in the dogma of discontinuing the injections with a suitable 
specific drug during an attack of epididymitis, because the latter 
is the result either of unsuitable treatment, lack of thoroughness, 
or disobedience of general instructions; but never caused by 
proper treatment. 

Several times I have observed epididymitis during a gonorrheal 
urethritis, which was characterized by a quotidian and a quartan 
type respectively. The swelling of the epididymis rapidly fol- 
lowed a chill and gradually disappeared with the return of a normal 
temperature. The patients had malaria fever long before the 
gonorrhea was contracted. I also had occasion to observe the 
same condition in a patient who had a gonorrheal epididymitis 
years before he contracted malaria. In all of them quinine acted 
promptly on the local trouble. 



COWPERITIS. 



Surgical relief Abscess formation is the usual termination of this complication. 

An abscess here should be opened by a liberal incision as early as 
recognizable, cleaned and packed with iodoform or vioform gauze. 
If the abscess has already ruptured into the urethra a catheter 
may be tied in the bladder for a few days to prevent urine infiltra- 
tion of the tissues. In the short time preceding the manifestations 
of an abscess, rest in bed, hot applications and opiates are service- 
able. 

Chronic cowperitis seriously handicaps the cure of a gonorrheal 
urethritis, and, if not recognized and duly treated, perpetuates the 
disease, because from this situation infectious material is con- 
stantly poured out into the urethra. The condition can only be 
recognized by palpation over a Benique or any other metal bougie 
of large caliber, or still better, by digital palpation of the perineum. 
The index finger is introduced into the rectum and its tip, turned 
forward above the external sphincter, presses against the rectal 
wall. The thumb on the perineum gradually pushes upon the 
tissues adjoining the raphe, proceeding along the bulbous por- 
tion as deeply as possible until a sort of gutter is formed. By 
means of this bidigital palpation a nodule may be felt, from the 
size of a pea to that of a hazelnut, attached to the lateral wall of 
the urethra; this is the Cowper gland. 

Massage Massage of the gland over a metal bougie, followed by anti- 

septic irrigation of the urethra, is rarely beneficial. It is best to 
extirpate it via the perineum. 



Diagnosis of 
chronic cow- 
peritis 



DISEASES OE THE URINARY APPARATUS 407 

INFECTION OF THE PARA- AND PERIURETHRAL 

DUCTS. 

This complication should be looked for in unduly prolonged 
gonorrheal urethritis. These ducts are found either around the 
meatus in the glans, especially in hypospadias, or on the mucosa 
close to the meatus. If they are infected pus exudes from the 
mouths of these blind canals upon pressure. If injections of a 
ten per cent, silver nitrate solution into the ducts are not suc- 
cessful in checking the suppuration, it is then best to obliterate 
them by a thin pointed galvano-cautery, or by electrolysis. If lo- Cautery and 
cated near enough to the meatus so that they can be safely opened e ectro ysis 
into the urethra, this should be done and the exposed surface cau- 
terized. 



SPERMATOCYSTITIS. 

The symptoms of the acute form resemble closely those of Abscess 
prostatitis and the therapy is practically the same as in the latter. 
If the inflammation advances to suppuration and the abscess does 
not soon rupture into the urethra, it must be opened. This can be 
done, through the rectum, but more safely through a perineal 
incision, the technique being identical with that of opening a Surgical relief 
prostate abscess. 

The treatment of chronic vesiculitis is the same as that of the 
chronic prostatitis, viz., massage, heat applied through the recto- 
phor, hot Sitz-baths, and the gonorrheal process in the urethra 
properly attended to. The patient may be informed of the prob- 
ability of relapse. In this event, hydrotherapy, Sitz-baths, and 
general hygienic measures seem to be more beneficial than local 
manipulations. 

Cystitis, pyelitis and pyelonephritis as complications of gon- 
orrhea will be discussed in their respective sections. The treatment 
of extra-genital complications and systemic infection does not come 
within the scope of this book. 



BARTHOLINITIS. 

In the inflammatory stage hot poultices should be applied and Heat and 
opiates given to relieve the pain. If the infection leads to abscess opia es 
formation a free incision should be made on the inner side of the 
labium and the abscess cavity thoroughly curetted. The incision Surgical treat- 
should commence below the upper margin of the gland and should 
extend downward in order to avoid wounding the vulvo-vaginal 



408 DISEASES OF THE URINARY APPARATUS 

bulb. The cavity should be cleansed with 1 in 500 sublamin solu- 
tion and the duct opened and treated in the same manner. This is 
facilitated by passing a fine probe which serves as a guide through 
the canal. 

The wound may be dried and packed with iodoform gauze, or 
better, gauze saturated in a ten per cent, aluminum acetic solution. 

The operation can be made painless by the application of a 
small piece of gauze saturated with a four per cent, cocain solution 
which is held to the surface to be incised for five minutes. 

In chronic cases with hypertrophic induration of the gland the 
latter should be excised and the wound-bed treated in the same 
way as an abscess cavity. 

Profuse bleeding might require a few ligatures or deep sutures 
which are to be tied over the gauze packing. 

These chronic suppurations, if unattended, not only propagate 
infection through intercourse but lead to recurring infections of the 
urethra and female genitals and also menace the life of the 
woman by puerperal sepsis. 
Method of Another simple measure of treatment for bartholinitis is rec- 

ommended by A. E. Gallant, applicable to those cases in which oc- 
clusion of the duct results in marked distention of the gland, caus- 
ing such discomfort as to demand immediate relief, which is af- 
forded in the following manner: 

"Excision of an Ellipse. — Expose the inner surface of the la- 
bium minus and inject into the mucous membrane over the most 
prominent portion, five to ten minims of four per cent, cocaine 
solution, or place a pledget of cotton saturated with ten per cent, 
cocaine solution between the labia, until anesthesia is complete. 

"With a pair of plain thumb forceps grasp and make traction 
on the most prominent portion of the gland (taking care not to 
rupture it), on the inner surface, and with scissors curved on the 
flat, cut out an ellipse of tissue, including mucous membrane 
and gland wall, to the extent of one-third of the sac. When the 
gland is markedly distended, the sac well thinned, the first cut will 
usually bring away enough of the sac, but in some instances the 
sac contracts so closely that it is necessary to cut away, in circular 
fashion, more of the wall. 

"Occasionally, where the gland has not been markedly distended, 
bleeding may necessitate the application of catgut ligatures at one 
or two points. 

"Immediately following the first cut of the scissors the con- 
tents gush out and the sac contracts, the swelling diminishes to one- 
third, leaving an irregular circular opening, the base of which is 
formed by the remnant of the sac wall. This presents an impor- 
tant point so frequently overlooked when incision for evacuation 



DISEASES OF THE URINARY APPARATUS 409 

of abscesses, viz., that with linear incisions the cut edges fall to- 
gether in close apposition and readily unite, sealing the cavity; 
whereas elliptical or circular incisions cannot assume a position 
favorable to such coaptation, and therefore remain open and drain 
the cavity and healing must take place from the bottom. When a 
true abscess is present the remaining sac wall will be cast off by 
granulation; but where the condition is that of a retention cyst, 
the edges of the sac wall and mucous membrane will unite to 
fill in the gap made by the excised mucous membrane. 

"The only dressing used is to place a pad of sterile absorbent 
gauze, upon which has been poured a small quantity of Van 
Arsdale's balsam-oil mixture (Bals. Peru, 5 per cent, 01. ricini 95 
per cent.), between the labia, to be changed and replaced by the 
patient each time she urinates. No packing or sutures are requir- 
ed, and the patient can at once walk with freedom from suffering, 
and with little interference with the ordinary gait. The healing is 
complete within from seven to ten days. 

"The other class of cases referred to is those in which infec- 
tion of the gland takes place, distention occurs to such an extent as 
to overcome the adhesions in the outlet, the duct is forced open, 
and the contents escapes through the natural channel. The duct 
may remain patent and the patient is then annoyed by a constant 
purulent discharge; in some causing irritation, in others severe 
pruritus and dyspareunia. 

"Unless these chronic forms can be treated during the stage 
when obstruction of the duct has resulted in distending the gland, 
the only means for radical cure is: 

"Excision of the Gland. — Whether we are dealing with a chronic 
infection of Bartholin's gland or of Skene's duct, the removal does 
not require any special surgical acumen. Excision of Skene's duct 
usually involves the floor of the urethra, and care must be taken 
to restore the latter in such a way as will not lead to cicatricial con- 
traction of the meatus externus. Through an incision in the vesti- 
bule, below the urethra, the thickened duct can be dissected out and 
the wound closed by catgut, and primary union expected. A linear 
incision below the gland of Bartholin, blunt dissection and closure 
of the cavity, will give an ideal result." (A. E. Gallant.) 

GONORRHEAL VULVO-VAGINITIS. 

Both conditions — vulvitis and vaginitis — may be discussed to- 
gether since both are usually observed together. Primary vaginitis 
is quite rare in the adult owing to the resisting power of the vag- 
inal epithelium. Most frequently the infection spreads over the 
vaginal mucosa from the cervical canal or from the vulva. 



410 



DISEASES OF THE URINARY APPARATUS 



Rest 
Douches 



Protargol 
Argyrol 



Sublimate 



Silver nitrate 



Ichthyol 



Argentamin 
Yeast 



The treatment of the very acute stage of vulvo-vaginitis con- 
sists in rest in bed, warm douches and care of the bowels. Most 
suitable are vaginal douches with mild silver solutions like pro- 
targol or argyrol. Of the protargol 1 grm. in 2,000 cc. of water 
(15 grains in two quarts) should be used; of the argyrol 4 grm. in 
2,000 (1 dram in two quarts). The water should have a tempera- 
ture of 110° F., and the douche repeated twice or three times a 
day. A gauze tampon moistened with a two per cent, protargol, 
or twenty per cent, argyrol solution is placed in the vulva and held 
in position by a gauze pad and a T binder. The tampon should be 
renewed after urination. 

The urethra being usually involved should be looked after in 
the manner described in the section on Gonorrheal Urethritis. 

As soon as the acute symptoms subside, which is recognized by 
a marked decrease of inflammatory swelling, irritation and dis- 
charge, the treatment is to be somewhat modified. A vaginal douche 
with two quarts of a warm solution of sublimate, 1 in 2,000 (15 
grains) is given twice daily, mornings and before retiring, and the 
previously mentioned medicated gauze tampon placed in the vulva. 
Every other day vagina and vulva should be locally treated with a 
four per cent, silver nitrate or five per cent, argentamin solution 
through a Ferguson speculum. In order to bring the solution in 
contact with the whole diseased area, we insert the speculum clear 
up to the cervix, pour the solution into the speculum and then 
withdraw the latter very slowly until its distal end approaches the 
vestibulum. By lowering its proximal end its contents are then 
emptied into a suitable vessel. 

When after repeated examinations the gonococcus is found to 
be absent the silver nitrate applications may be gradually discon- 
tinued and ichthyol substituted. The latter is most conveniently 
employed in the form of vaginal balls which should be inserted 
as high up into the vagina as the finger will reach. They may 
be used every evening following the sublamin douche and left in 
the vagina where they melt completely within a short time. 

The treatment of chronic vulvo-vaginitis is practically the same 
as of the acute form except that the silver solutions employed 
ehould be stronger. Silver nitrate may be used as strong as six 
per cent., and argentamin ten per cent. 

The yeast treatment occasionally seems to exert some influence 
in very stubborn cases of vaginitis. It is employed as a paste made 
from cerevisine and glycerate of starch. A gauze or cotton tampon 
dipped in this paste is placed in the vaginal vault, after a preceding 
cleansing douche, and left therein for from six to twelve hours. 
The treatment may be repeated daily or every other day. 






DISEASES OF THE URINARY APPARATUS 411 

Great caution should be exercised in pronouncing such pa- 
tients cured, as the disease may exist in a latent stage for quite a 
while. 

CHRONIC GONORRHEAL URETHRITIS. 

The multitude and diversity of the lesions; their extent and 
localization; the frequency of complications; and the involvement 
of the urethral appendages all tend to render the treatment of 
chronic urethritis rather difficult which therefore calls for a great 
deal of experience and carefulness from the physician. 

Chronic urethritis appears in two different types : 

1. The glandular and periglandular form (the superficial Two types of 
catarrh) and, chronic 

2. As an infiltrating process, penetrating into the submucous 
tissues and even into the corpus cavernosum. 

Frequently both types are represented in one case. 

In the earlier stages the disease extends over a large surface 
of the mucosa, while later it becomes localized to one or more 
small areas. 

Most commonly the posterior urethra is involved, but occasion- 
ally the process remains confined to the anterior urethra. Consid- 
ering these points it is obvious that a successful management of the 
disease requires an exact diagnosis of the nature and extent of the 
lesions. In this respect the physician familiar with the use of the 
bulbous bougie, the urethrometer, and the urethroscope is at a de- 
cided advantage over those whose methods are but tentative; and 
while I am of the opinion that every practitioner should, and can, 
learn to successfully treat acute urethritis, I also believe that the 
management of the chronic type must oftentimes be left to the 
experienced specialist. 

The "two-glass test" to locate the extent of the trouble, while Two-glass test 
still employed, is useless. It is only of value when preceded by a 
cleansing irrigation of the anterior urethra. In the latter case, if 
both portions are clear and free from shreds, the posterior urethra 
may be considered normal. If the first portion is cloudy or clear 
but carrying shreds, and the second portion normal, the posterior 
urethra is evidently involved. 

If irrigation does not precede such a test and the first portion 
passed is cloudy or contains shreds, it is impossible to say from 
which part of the urethra the secretion was gathered. Many times 
such a finding is referred to the anterior urethra, and in this way a 
chronic posterior urethritis perpetuated. There are, however, cases 
in which the glandular apparatus of the prostatic urethra is so 
slightly affected that it does not show in the first portion unless 



412 



DISEASES OF THE URINARY APPARATUS 



Topical appli- 
cations 



Irrigations 



Treatment of 
the deep 
urethra 



the gland is massaged preceding the irrigation and the subsequent 
urination. 

According to the two main types of chronic urethritis, the 
treatment is selected in the following manner : 

In the early stage, in which the disease extends in continuity 
over a larger area, irrigations or topical applications should be 
employed, the latter being especially useful to remove granulations 
and stimulate the growth of epithelium over the many minute 
erosions. Ultzmann's brush apparatus may be used but any ure- 
throscopic tube of 26 to 30 Fr. caliber will serve the purpose as 
well. The brush, saturated with a one per cent, to two per cent, 
solution of nitrate of silver, is introduced through the tube, either 
to the internal or external sphincter, this depending on the extent 
of the urethritis. Both tube and brush are then withdrawn, the 
brush with a rotary motion. 

The irrigations are performed with syringe and catheter, or 
with an irrigating apparatus. 

Simpler than the irrigating apparatus, and in many respects 
more practicable, and serving the same purpose, is the hand 
syringe of a capacity of 100 to 150 cc, with a detachable shield 
and rubber nozzle. With this the physician has it actually "in his 
hand" to determine and regulate the pressure desired to balloonize 
the anterior urethra, or to irrigate the posterior urethra and the 
bladder. 

C. L. Wheeler's (Lexington, Ky.) rubber shield and tip, which 
may be attached to a hand syringe or connected with an irrigator, 
is also a very useful and practical appliance for the same purpose. 

When using the first method to irrigate the anterior urethra a 
soft rubber catheter is attached to a hard rubber or glass syringe 
holding 100 to 150 cc. and carried down into the bulbous urethra 
to the external sphincter; and just beyond this muscle if it is de- 
sired to irrigate the posterior urethra. In the latter case the fluid 
should be injected very slowly in order to avoid undue pressure 
when the liquid is forced through the narrow space between the tube 
and the urethral wall. Neglect of this precaution causes much 
tenesmus, and leads to vesiculitis and epididymitis. To the end 
of preventing these complications we employ a silkweb catheter 
which, at its vesical end, is perforated by many little openings. In 
this way the force of the stream is broken, and the fluid is more 
evenly distributed over the whole area. 

While irrigating the anterior urethra the part should be slightly 
and repeatedly distended by compressing the meatus around the 
catheter for a few seconds. In this way the medicated fluid is 
brought into contact with every diseased spot on the unfolded 
mucosa. 



DISEASES OF THE URINARY APPARATUS 413 

The temperature of the solutions injected should be 106 to Temperature of 
110 degrees F., and the urine should be voided before each treat- fl^ 1 ( f a lon 
ment. 

If gonococci or other micro-organisms are still present in the 
secretion, the following solutions may be employed: 

Protargol, one part, in from 1,000 to 300 of distilled water. Concentration 

Silver nitrate, one part in from 4,000 to 1,000 of distilled water. 

Mtric acid, one part in from 3,000 to 1,000 of distilled water. 

From a pint to a quart, according to the strength of the so- Quantity to be 
lution, should be used, and the treatment repeated every day, or 
every other day. In the latter case the patient may use an astrin- 
gent injection on the intervening day. 

After the secretion has lost its purulent character and appears Catarrhal 
to be free from bacteria, permanganate of potash, or some other 
mild antiseptic and astringent may be used. The strength of the 
permanganate of potassium solution for the anterior urethra varies 
from 1:4,000 to 1:1,000; and for the posterior urethra from 
1 :8,000 to 1 :4,000. 

A combination of sulphate of zinc, alum and carbolic acid in 
one-eighth to one-fourth per cent, solutions is also beneficial. Of 
this preparation it is convenient to have a one per cent, stock solu- 
tion which, by the addition of water, is diluted to the desired 
strength. 

If, however, infection of the deep urethra is suspected, these Combination of 
irrigations should be followed immediately by an instillation of instillation 
three to six cc. of a one to four per cent, protargol solution, or 
one to four cc. of a one-eighth per cent, to one-fourth per cent, silver 
nitrate solution, or a twenty per cent, argyrol solution. 

When using the irrigation method it should be remembered that 
the bladder must not be rapidly distended with large quantities of 
fluid — not more than 150 cc. are permissible at a time. (Compare 
section on Cystitis.) 

TECHNIQUE OF IRRIGATION (VALENTINE). 

"The Irrigator. This apparatus consists of a board, with a Valentine's 
brass rod attached. Eeadily sliding upon the brass rod is a metal tec nl( l ue 
block, connected by a strong bar to a collar. This firmly holds a 
percolator of a capacity of 1,000 cc. (about one quart). The 
opening that interrupts the completeness of the collar permits easy 
removal of the percolator when required. The nipple of the perco- 
lator is inserted into a soft-rubber tube seven feet long. The distal 
end of this rubber tube is passed through a stopcock, whose essential 
parts are a ring for admission of the fourth finger ; a sliding flange 
to increase or decrease the pressure of the fluid ; a shield to catch the 
fluid that spurts from the urethra and divert it into a basin held by 



414 DISEASES OF THE URINARY APPARATUS 

the patient; a small ring to suspend the stopcock when not in use. 
A urethral nozzle inserted into the rubber tube, projecting through 
the stopcock. 

"The board has brass plates above and below, perforated for 
screws by means of which the apparatus is attached to the wall. 

"The variations of pressure required for anterior and intra- 
vesical irrigations are accomplished by the action of the right thumb 
and index finger on the stopcock, and not by variations in the height 
of the percolator. The elevation of the latter should always re- 
main the same; it is lowered only for the purpose of filling or 
cleaning. 

"Experience has demonstrated that when the top of the irri- 
gator board is attached to the wall at an elevation of nine feet from 
the floor, sufficient pressure is obtained for all purposes. 

"If the stopcock is taken in the right hand, and the fourth 
finger passed through the large ring on the metal tube, the thumb 
and the index finger will easily reach and control the flange. On 
pushing it forward it compresses the clips, narrowing or even 
closing the lumen of the rubber tube; on drawing it back, the 
rubber tube resumes its full caliber. One or two efforts will teach 
the physician to allow single drops to escape from the nozzle. By 
gradually drawing back the flange the stream is increased until a 
strong jet carries over six feet. All variations in the flow, from 
mere drops to a strong jet, are accomplished with the percolator 
raised to its greatest height, viz., nine feet from the floor. The 
value of so controlling the flow by slight contraction of the thumb 
and index finger will become more evident on considering the 
technique of irrigations. 

"The nozzles are of glass that can be easily sterilized. Their 
various shapes are shown in figure. 

A is a pointed nozzle for irrigating a normal meatus. It is im- 
portant that the irrigating fluid have an easy exit as it has en- 
trance into the urethra. The point of this nozzle allows washing 
the entire urethra, and the meatus as well. 

"B is a dome-shaped nozzle devised to accomplish anterior 
and posterior irrigations without changing the nozzle, when a 
meatus is congenitally very large or has been made so by meatotomy. 

"C is a blunt nozzle for use when a congenitally very small (pin- 
point) meatus would otherwise prevent irrigation, or when the nor- 
mal meatus is so swollen as to prevent the introduction of nozzle A. 
Its orifice then is merely pressed against the meatus and the stream 
so directed through it into the urethra. 

"D is intended for irrigations of the female urethra and bladder. 
Its shape is the same as nozzle A; its length, however, is three 
times greater. The reason for its increased length lies in the fact 



DISEASES OE THE URINARY APPARATUS 415 

that all females must be irrigated in the recumbent posture, and 
for the protection of thighs (from soiling with irrigating fluid), 
as well as for self-evident anatomical conditions, the shield must 
be brought down between the thighs. If the nozzle were as short as 
the others the shield would prevent it coming into contact with 
the meatus. 

"Attachment of Nozzles. — The nozzle appropriate for the size 
of meatus being selected with sterilized fingers, its tubular end 
is easily inserted into the rubber tube projecting through the stop- 
cock. After the tubular end of the nozzle is firmly inserted, the 
rubber tube should be drawn backward until the shoulder of the 
nozzle is arrested by the metal projection of the stopcock. This 
then holds the nozzle firmly, making it practically one piece with 
the stopcock. 

"It would be criminal negligence to subject any patient to the 
danger of infection by using a nozzle that had been employed in a 
previous case. This danger is easily avoided by the following 
steps : 

"Immediately after irrigation hold the shield with the used 
nozzle still in place, under boiling hot, running water. 

"Bemove the nozzle and place it into a strong bichloride solu- 
tion, kept ready in a glass dish for that purpose. 

"When the day's office work is done, boil all the used nozzles 
for ten minutes in strong caustic soda solution. 

"After this boiling place the nozzles in a strong (1:1,000) bi- 
chloride solution, kept in a covered glass or china dish reserved 
for sterilized nozzles. 

"Einse each nozzle again in clean hot water before using. 

"While the steps described above suffice for the sterilization of 
nozzles ordinarily, it is wise to take extra precautions when a syph- 
ilitic has been irrigated. In a large practice, where many nozzles 
are used, it is well to break the nozzle after employing it on a case 
with lues. If economy prompts keeping such nozzles, each one 
should be boiled separately and kept in a test tube filled with mer- 
curic bichloride, 1 to 1,000. The test tube may be closed with a 
rubber cork, and marked with a number or letters to designate the 
patient for whom the nozzle is reserved. 

TECHNIQUE OF AN ANTERIOR IRRIGATION. 

"1. Stand on the patient's right side. 

"2. Cleanse the penis, foreskin, glans, and meatus with cot- 
ton tampons soaked in corrosive sublimate, 1:3,000. If it is pre- 
ferred to accomplish the cleansing with the irrigating solution, 
then 



416 DISEASES OE THE URINARY APPARATUS 

"3. Take the stopcock in the right hand, and for additional 
safety pass it nnder running, boiling water into which a small 
quantity of the irrigating fluid should be allowed to escape, then 
close the flange. 

"4. Take the penis in the left hand, holding the left corpus 
cavernosum by the second, third and fourth fingers in such a man- 
ner that their tips rest lightly upon the urethra. The left thenar 
eminence, by being pressed inward, compresses and almost grasps 
the right corpus cavernosum. The bent thumb and index finger 
are thus left free for manipulation of the foreskin, glans, and 
meatus. This manner of holding the penis will at first effort ap- 
pear to cramp the hand, but after two or three irrigations it will be 
found the most effective and easiest. 

"5. Gently draw the flange of the stopcock back by contract- 
ing the right thumb and index finger. This will allow a fine 
stream to escape from the nozzle. Direct this stream to the outer 
surface of the foreskin until all its parts are thoroughly cleansed. 

"6. Increase the stream slightly while directing it to the open- 
ing of the foreskin. With the left thumb and index finger slowly 
evert the foreskin, and, as its mucous lining is thus being exposed, 
wash each part as it comes into view. 

"7. When the entire foreskin is retracted, wash the sulcus be- 
hind the corona, the glans, the sulci at either side of the framum, 
and the lips of the meatus in the same manner. When the fore- 
skin is so tight that it cannot be everted, drop the penis and take 
up the top of the foreskin with the left thumb and index finger. 
This will leave the opening of the foreskin slightly gaping. Insert 
the nozzle into the opening of the foreskin and increase the force 
of the stream until the preputial pouch is thoroughly ballooned. 
Give the tip of the nozzle every possible direction, so that the 
pouch may thus be as effectively cleansed as possible. 

"8. After cleansing the foreskin, glans, etc., and holding the 
penis as indicated above, contract the thumb and index finger upon 
the glans so as to open the meatus. 

"9. Direct the stream at first gently and then with increasing 
force into the opened meatus, until all visible excess of secretion 
is washed from it. 

"10. Bring the nozzle closer and closer to the meatus until 
its point is within the lips. 

"11. Compress the urethra with the tips of the left second, 
third and fourth fingers, to entirely occlude it. 

"12. Augment the force of the flow until the fluid spurts from 
the meatus in such a manner that it is received by the shield and 
flows from it into the basin held by the patient. The impact of 



DISEASES OF THE URINARY APPARATUS 417 

the fluid is felt against the tip of the middle finger, where it com- 
presses the urethra. 

"13. When one-fifth of the contents of the percolator are 
consumed in the irrigation of the anterior third of the anterior 
urethra, the middle finger is relaxed and the fluid's impact is im- 
mediately felt upon the tip of the third finger that compresses the 
urethra. 

"14. The same procedure is successively observed regarding 
the urethra compressed by the fourth left finger, and the impact of 
the fluid, with increased force, is sent to the bottom of the anterior 
urethra; i. e., to the anterior surface of the mucosa in front of the 
compressor. 

"During each step of an anterior irrigation enough force must 
be used to fully dilate (balloon) the urethra. The nozzle should 
never occlude the meatus entirely, especially when strong solutions 
are used, lest they be forced beyond the compressor into the bladder. 

"The division of the amounts of fluid used for each part of the 
urethra will soon become so much a matter of routine that the op- 
erator need not observe the percolator to guide him in this respect. 

"After each irrigation a layer of absorbent gauze soaked in sub- 
lamine should be placed upon the glans so as to receive any subse- 
quent discharge, prevent as far as possible auto -reinfection, and 
to keep the clothing clean. If the foreskin is absent, or too small 
to hold the cotton, it should then be fixed in place by means of a 
light gauze bandage. The patient should be instructed to apply a 
clean piece of gauze, soaked in sublimate, after each urination. 

"All the steps of an irrigation can, without any special dex- 
terity, be so conducted that neither the patient's garments, his per- 
son, nor the office floor become soiled. Nothing need be stained, 
except the operator's left fingers, when using strong solutions of 
potassic permanganate, and then the hands can be quickly cleaned 
with oxalic acid or sodic bisulphide. 

"When properly carried out an irrigation is as painless as it is 
cleanly." 

Technique of Posterior or Intravesical Irrigations. — Keeping in 
mind what a feeble bundle of muscular fibers constitute the sphinc- 
ter vesicas, it is evident that any appreciable quantity of fluid car- 
ried into the posterior urethra under strong compression must enter 
the bladder. Hence irrigation of the posterior urethra distinctly 
implies irrigation of the bladder at the same time. For conveni- 
ence, therefore, irrigations of the posterior urethra are called intra- 
vesical irrigations. 

The patient is prepared and sits, stands, or lies down, as may 
be necessary. 



418 DISEASES OF THE URINARY APPARATUS 

The Irrigation. 1. Perform thoroughly all the steps de- 
scribed under Anterior Irrigation (as above), using only half the 
quantity of fluid there mentioned. 

2. Hold the penis firmly, while gently sinking the nozzle into 
the meatus until the latter is entirely occluded thereby. At the 
same time slowly increase the force of the flow by drawing back 
the flange of the stopcock. 

3. As the urethra is felt distending under the left finger tips, 
order the patient to breathe deeply and slowly, and to make 
efforts at urination. 

4. Ordinarily when the third step of this operation is being 
performed, a sensation of purling of the liquid, as it enters the 
bladder, will be communicated to the left fingers. 

5. After one-half or three-quarters of a minute the inflow will 
become less accentuated and slower, as the bladder becomes filled. 
Then slowly push forward the flange of the stopcock, to diminish 
the force of the flow, until it is stopped. By close observance of 
this technique the bladder can be entirely filled without producing 
pain or even an urgent desire to urinate. 

6. Rest the penis on the margin of the basin leaving the left 
hand free. 

7. Place the stopcock in the basin; pass the right thumb 
through its large ring; pass the right fingers to the outside of the 
basin to hold it firmly with the stopcock. 

8. Extend the left hand to the shelf on which the glass urinals 
are kept (one of which may also conveniently rest under the pa- 
tients chair), take one and hand it to the patient. 

9. Order the patient to take his penis with his left hand and to 
direct it toward the urinal, which he holds in his right. 

10. Take the basin and stopcock from the patient's lap. 

11. Order the patient to void the bladder into the urinal; some 
can do this sitting, others must rise for the purpose. 

12. While the patient is emptying the bladder pour the con- 
tents of the basin into the sink and wash out the basin with warm 
water, if the patient is to be immediately irrigated again. If not, 
wash the basin with boiling water^ and place it with the used basins, 
to be thoroughly cleansed after office hours. 

13. Without removing the used nozzle from the stopcock, hold 
both under running, boiling water for a few moments. Then re- 
move the nozzles to a dish containing sublamin, 1 in 1,000. After 
office hours boil the used nozzles in water and caustic soda; rinse 
them in clean water and place them in a dish containing sublamin 
1-1,000. 

All the steps of intravesical irrigation, like those of anterior 
irrigation, can be effectively, thoroughly, and painlessly performed 



DISEASES OF THE URINARY APPARATUS 419 

without soiling any part of the patient's person or body, or the 
physician's office. 

Impediments to Irrigation. — In some cases, when for any reason 
the preparations for irrigation are unusually prolonged, or when 
the patient is nervous, there may be a somewhat free outpouring of 
urine from the kidneys after the patient has emptied his bladder. A 
small quantity of urine in this viscus may set up such a spasm of 
the compressor that when an intravesical irrigation is attempted it 
cannot be overcome by the pressure of the irrigating fluid. Such 
a patient should be ordered to again empty his bladder ; the irriga- 
tion will then be quite easily performed. 

When potassium permanganate is used in a case in which some 
urine is withheld, it will be returned from the bladder either tur- 
bid or of a light straw or brownish hue. A second irrigation will 
then produce an unchanged return fluid. 

Some patients, in making violent respiratory efforts, coupled 
with endeavors to urinate during irrigation, will force the com- 
pressor into a firm tonic spasm. It is well, in such instances, to ask 
the patient to desist from his efforts, and, while reducing the hy- 
drostatic pressure, to divert his attention from the matter in hand. 
This is best accomplished by some witticism; not, however, one of 
which the patient is the object. The slightest tendency of the 
patient to laugh is instantly accompanied by a relaxation of the 
compressor and a consequent inflow of the irrigation fluid into the 
bladder." (Valentine.) 

The intravesical irrigations may be performed once daily, begin- Frequency of 
ning with potassium permanganate solution of 1 :8,000 ; on the sec- irn S atlons 
ond day the strength of the solution may be increased to 1:7,000; 
on the third day 1:6,000 may be used, and if no reaction follow a 
further increase to 1 :4,000 may be employed on the fourth and 
subsequent days. Some patients' bladders will comfortably bear 
stronger solutions. 

If in five or six days the urine does not indicate complete sub- 
sidence of the posterior urethritis, mercuric bichloride may be added 
to the potassium permanganate solution last employed. The addi- 
tion of the bichloride should at first not be stronger than 1 :50,000. 
On the second day this may be made 1 : 40,000 ; on the third day 
1:30,000; on the fourth day 1:25,000. Only in very persistent 
cases can 1 : 20,000 be employed. 

Some cases do better with the bichloride alone, and in the so- 
lutions above indicated. 

Occasionally a case will be found in which neither the perman- 
ganate nor the bichloride, nor both, in combination, yield prompt 
effects. Then silver nitrate may be employed in solutions of 1:10,- 
000; 1:4,000; 1:3,000; or 1:2,000, using the mildest on the first 



420 



DISEASES OF THE URINARY APPARATUS 



Combination of 
dilatation and 
irrigation 



Technique of 
dilatation 



Covers 



Lubricant 



day and daily thereafter increasing the strength, but not beyond 
1 :2,000. 

If the urethritis has caused structural changes in the mucosa, 
or involves the deeper tissues, or has invaded the ducts of the 
crypts, glands and follicles of the channel, dilatation combined 
with irrigation is required to promote absorption of the infiltration, 
restore, as far as possible, the elasticity of the urethral wall, and to 
remove, mechanically, the pathologic secretions. 

Without a doubt it is also the thermal effect of the hot solu- 
tions which assists materially in the process of absorption and in 
the destruction of the bacteria in the deeper tissues. 

The dilatations are effected in the following manner : 

Previous to the introduction of any instrument every effort 
should be made to prevent carrying with it infection into and 
from one part of the urethra to another. Naturally, in the light 
of our present knowledge, no pretense can be made to a rendering 
of the urethra aseptic ; yet every precaution should be employed to 
reduce the danger of infection. 

Cleansing, preliminary to urethral instrumentation, is most 
easily effected by irrigation of the channel. Urethral washings may 
be performed with large syringes, such as those known as the 
Guyon or Janet syringes, or with the irrigator. Dilators may be 
inserted into the urethra in the same manner as most other instru- 
ments. All dilators should be clothed with a rubber cover before 
their insertion into the urethra. 

Clothing dilators with these covers is performed by grasping 
the mouth of the cover with the left fingers and drawing it over the 
dilator. This can always be done with ease if the cover be thor- 
oughly dry. No attempt should be made to apply a cover if it re- 
tains the slightest moisture from sterilization. 

Covers must be sterilized after each use. To this end they must 
be scrubbed in hot water with soap, each one then wrapped in a 
sterilized gauze napkin and boiled seven minutes in a one per cent. 
carbolic acid solution. (I consider plain water sufficient.) They 
may then be left to dry for use. 

Easier still is dry sterilization by formalin fumes, after scrub- 
bing with soap and hot water. 

After a dilator has been clothed with its cover it should be 
lubricated from its point for half an inch along its shaft. Lubri- 
chondrin is most useful for this purpose, made according to Pro- 
fessor Bangs' direction. It is composed of the gelatinous substance 
of chondrus crispus (Irish moss) to which eucalyptus oil, 1:1,000, 
and formaldehyde, 1 : 1,500, are added. Lubrichondrin is sold in 
collapsible tubes and in glass-stoppered, salt-mouth bottles. The 
former can be resterilized by boiling the closed tube in water. In 



DISEASES OF THE URINARY APPARATUS 421 

using a tube its bottom should be compressed to force out the con- 
tents, of which the necessary quantity can be placed directly upon 
the dilator cover. When the bottles are used about a sixth of a 
drachm of lubrichondrin may be poured into a sterilized Petri dish, 
whence it can be readily taken upon the point of the dilator. 
Another good lubricant is the following preparation : 

Gum. tragacanth, 2.50 (40 grains) 

Glycerin, 10. (2y 2 drachm) 

Sol. acid carb. 3 per cent., 90. (3 ounces) 

or the KY lubricant manufactured by Van Horn and put up in 
tubes. 

When a dilator for the anterior urethra is to be used it is best 
held as if it were a pen grasped for writing. 

The selection of a dilator is necessarily predicated upon the Selection of 
location of the disease and the caliber of the urethra. If the an- 1 a or 
terior urethra alone requires treatment and the urethral caliber is 
still small, Oberlaender's anterior dilator has preference. This 
instrument has a slight curve near its tip, to readily accommodate 
it to the normal curve of the anterior urethra. The tip is rather 
small, permitting its insinuation through a stricture so narrow that 
it will let no instrument beyond 10 Fr., pass. The smallness of 
the tip should be well kept in mind when using this instrument; 
because if the greatest gentleness is not employed it may engage- 
in a mucous fold, a wide open duct mouth, or a previously made 
false passage. The instrument will then not proceed, and the 
slightest force applied may produce serious urethral laceration. 

When an obstacle of any kind impedes the easy progress of the Technique 
dilator, the instrument must be immediately withdrawn and a suc- 
cessive systematic series of other directions given to its point. 
With well-developed tactile sense, however, the surgeon will be 
enabled by gently touching all parts of the obstacle to form a clear 
mental picture of its character. When the point of the instrument 
has found the correct urethral lumen it will easily and smoothly 
glide to its destination, unless again impeded by further obstacles, 
which then will have to be overcome in the same manner as the 
first. 

The curve of the Oberlaender anterior dilator, being the near- 
est approach to that of the anterior urethra, therefore exercises 
the most direct pressure upon its roof and floor without distorting 
the canal. This consideration of the urethral curve is unnecessary 
when the channel is or has become sufficiently capacious to easily 
admit the Kollman anterior dilator, which is described below. 



422 



DISEASES OF THE URINARY APPARATUS 



Steps in 
procedure 



Kollman's 
dilator 



The steps necessary to inserting the Oberlaender anterior di- 
lator are as follows : 

1. The patient should lie on a firm table with his legs ex- 
tended, a sterilized towel is placed upon his abdomen, covering 
the pubis, with another over his testicles and thighs. The penis 
rests upon the latter towel. 

2. After the penis has been cleansed the glans is taken between 
the left thumb and index finger. 

3. The penis is gently placed in the direction of the right thigh, 
on a line continuing the left Poupart's ligament. 

4. The clothed Oberlaender anterior dilator is then taken as 
before described, like a pen, with the face of the dial resting upon 
the interspace between the right thumb and index finger. 

5. The tip of the instrument is inserted into the meatus. 

6. After overcoming the angle at which the fossa stands to 
the uretha, the penis is drawn over the dilator, as a glove is drawn 
over a finger, but far more gently. The tip of the instrument is 
thus guided along the floor of the uretha until the bulbous por- 
tion is reached. The surgeon then experiences a sensation of re- 
duced resistance at the instrument's point. 

7. Without increasing the pressure, but keeping the tip im- 
mobile, the surgeon carries the penis, containing the dilator, in 
about a three-quarter circle in the same place, around and beyond 
the patient's left side, until the dial of the dilator faces the linea 
alba at its commencement above the pubis. 

8. Keeping the tip within the bulbous portion the dilator is 
now gently tilted from the floor to the roof of this region, and the 
penis with the dilator raised until it stands at right angles to the 
body. 

9. The patient's elbow, either right or left, is rested against 
his side to steady his arm. He is then asked to grasp the dilator 
where its cover projects from the meatus, and hold it in this po- 
sition. 

10. If the dilatation is to be in prolonged session it will ma- 
terially contribute to the patient's comfort to raise the back of the 
table to about forty-five degrees and elevate its foot. 

Further manipulations with the Oberlaender anterior dilator 
do not differ essentially from those to be described in discussing 
other dilators. 

Kollman's four-branched dilator for the anterior urethra is in- 
tended for use when the urethra's capacity is, or when previous di- 
latations have brought it to, No. 21 Fr. The technique of its em- 
ployment is the simplest of all dilators. After the dilator has been 
clothed with its cover and lubricated the penis is held in an erect 
position by the left hand. The dilator is then slowly inserted, the 



dilator 



DISEASES OE THE URINARY APPARATUS 423 

general rules before mentioned being observed. The dial may be 
placed in any direction, as the instrument when closed is perfectly 
round. The one of choice, however, will naturally be that in which 
the light strikes the dial, so that the figures thereon can be easily 
read. 

Oberlaender's Benique curve dilator exercises pressure only Oberlaender's 
within the posterior urethra. The technique of its insertion is as 
follows : 

1. Follow all the steps, from 1 to 8 inclusive, laid down for 
the introduction of the Oberlaender anterior dilator. 

2. When the tip of the instrument has been raised to the roof 
of the bulbous portion, guide it gently through the compressor 
while letting the handle sink between the patient's thighs. In this 
motion contact of the tip with the delicate and sensitive structures 
at the floor of the posterior urethra is avoided. 

Undeniably brilliant results are obtained in affections of the 
posterior urethra from the use of this dilator, without disturbing 
the anterior urethra. In the premature ejaculations due to irritabil- 
ity of the posterior urethra from masturbator's chronic hyperemia, 
it often exercises a salutary effect. But it is not "an instrument 
that can be recommended to any save those whom a large experience 
has made familiar with intra-urethral work. The very great Benique 
curve, alarming as it may appear to the patient, allows the instru- 
ment to lie very easily in the urethra, without making any traction 
whatever upon its normal bend. But this very curve and its small 
tip make its introduction safe only in trained hands. 

Kollmann's four-branched dilator for the bulb and posterior 
urethra is a much safer instrument to use. It cannot, however, be 
employed through an anterior urethra whose capacity is less than 
No. 21 Fr. Its large tip excludes the danger of injury, unless 
violence is applied. Its G-uyon curve, about one-half of that of 
the Benique, does not exercise any appreciable traction upon the 
urethra, while its great weight adds to the ease of its introduc- 
tion. The technique thereof is the same as that laid down for the 
Oberlaender posterior dilator. 

Oberlaender's curved dilator for the posterior and anterior 
urethra may be used when both these regions require dilatation. 
The technique of its introduction is identical with that given for 
the Oberlaender Benique-curve dilator. The angle at which it 
should be depressed between the thighs governs the dilatation that 
is to be done within the bulbous portion or beyond. Dilatation of 
the anterior urethra is accomplished at the same time. 

Kollman's four-branched Ouyon-curve antero-posterior dilator 
is applicable when both urethras require treatment and permit the 
passage of an instrument over No. 21 Ft. The technique of its 



424 DISEASES OF THE URINARY APPARATUS 

insertion does not differ from that before described for the in- 
struments intended for these regions. 
Technique of The technique of dilatations is the same for all dilators, viz. : 

1. After the instrument has been placed in the necessary po- 
sition, so that the region known to be diseased embraces the branches 
of the dilator, it is held motionless long enough to allow the dis- 
comfort of its presence to pass off, should such discomfort be ex- 
perienced at all. This period varies from a few seconds to half 
a minute. During this time the penis is held steadily by the left 
hand and drawn out to its full length, while the right hand keeps 
the dilator immovably in its position. 

2. Grasp the penis with the four left fingers and palm, and 
extend the left thumb to the ring at the dilator's handle, thus 
holding both penis and the dilator immovably together. 

3. With the right thumb, index and middle fingers take the 
large screw-head or disc at the handle of the dilator and very 
gently turn it to the right. Continue this until the first slight re- 
sistance to its easy progress is felt. 

4. If the patient is not extraordinarily timorous it will then 
be well to entrust the dilator to him for a few moments. It will 
occupy his attention and remove any apprehension he may have 
of pain that may be produced. At the same time it avoids cramp- 
ing the surgeon's fingers, which interfere with further delicate di- 
latations. The patient may be instructed to avoid cramp by hold- 
ing the dilator with the other hand, when the one grows fatigued. 

5. At the first seance leave the dilator at the first point of re- 
sistance for from three to five minutes, unless an especially spongy 
mucosa, as evidenced by bleeding, urethrospasm, hyperesthesia, or 
fear of pain, necessitates its removal before. 

6. Close the dilator's branches by very slowly turning its 
screw-head to the left. In doing so, watch the dial and turn the 
screw-head no farther than to leave it open one-half or one num- 
ber Fr. to preclude the very remote and most unusual, but possi- 
ble, accident of a collapse of the rubber cover, permitting the 
branches, if then closed entirely, to grasp the urethral mucosa. 

7. Eemove the Kollmann anterior dilator by drawing the penis 
back with the left hand and at the same time drawing the dilator 
from the urethra with the right. Eemove any one of the other 
dilators by tilting the anterior margin of the instrument as if to 
dip it into the umbilicus; the penis will then drop between the 
legs, after the urethra has painlessly slid from the rubber cover. 

8. After each dilatation irrigate the region that was invaded; 
i. e., after an anterior dilatation, irrigate the anterior urethra ; after 
a posterior dilatation, irrigate the bladder. The solution most fre- 
quently employed for this purpose is potassium permanganate, 



DISEASES OE THE URINARY APPARATUS 425 

1:6,000. In some cases this proves quite irritating after dilata- 
tion; then it may be reduced to one-half this strength, viz., 
1 : 12,0 00, or a four per cent boric acid solution may be substituted. 
When the urethra harbors many other bacteria besides gonococci, 
or without them, silver nitrate, 1:10,000 or 1:6,000, or stronger 
if it can be borne, will be found effective. 

Irrigations should never be omitted after dilatations or indeed Irrigation fol- 
any urethral instrumentation. Without them the discharge is ma- fo™ s l a a " 
terially increased and often persists several weeks. Pain on and 
even between urinations may become quite severe and all the ap- 
pearances of a new gonorrhea may set it. The cause thereof is evi- 
dent. If gonococci are squeezed from the mouths of ducts, or from 
structural interstices, they may infect urethral regions that had re- 
turned to the normal state or that had remained free from infection. 

The results of the omission of irrigations after instrumentation, 
if they portend nothing further, would entail a delay in dilatations 
until the reawakened acute conditions had yielded to additional 
treatment. 

But another greater and more immediate danger attends omis- Urethral fever 
sion of irrigations; that is, urethral fever ("catheter fever"). It 
will suffice to say here that since making it an inflexible rule to irri- 
gate after each instrumentation, not a single case of urethral fever 
has resulted. 

Frequently on the morning after a dilatation followed by ir- Reaction 
rigation the patient will find a slight increase of the discharge. If 
this continues until the second morning, the urthra should be again 
irrigated on that day ; rarely will a third irrigation be required. 

The frequency of dilatations, the amount of dilatation and its Frequency and 
duration at each seance must necessarily be governed by the con- ^natation 
dition of each case, the toleration of the patient, and the results 
of the preceding dilatations. 

A good average working list of rules to keep within the limits Rules and 
of safety is: variations 

(1) Begin with two dilatations weekly. 

(2) Increase each dilatation one-half number Fr. over the 
preceding number reached. 

(3) Prolong each seance two minutes. The longest seance, 
however, a patient can generally endure is forty-five minutes. (I 
do not extend the time beyond fifteen minutes. — Author's note.) 

Variations from the above may become necessary : 

1. When increase of discharge persists, as it may in very rare 
cases, beyond three days. It must then be controlled by irriga- 
tions. 

2. When marked improvement in the general and local con- 
dition shows that the intervals between dilatations may be ex- 



426 DISEASES OF THE URINARY APPARATUS 

tended. Experience has shown that recurrences are most likely to 
result when the intervals between treatments are too suddenly 
made. Therefore the extension of the intervals should be grad- 
ual. Thus, for instance, if a patient has been treated on Mon- 
days and Thursdays, and it be determined on a Monday to extend 
the intervals between his visits, a risk would be incurred by asking 
him to omit the treatment for a week. Therefore the next appoint- 
ment should be made for Friday. If then he is found in continued 
improvement, the following visit is set for Wednesday, and each 
interval increased by one day in this manner. 

3. When it is found that the usual increase of dilatation by 
one-half Fr. over the preceding number, or even the preceding 
number itself, cannot be reached without producing even slight 
pain, the patient may explain the condition by an intercurrent di- 
gression into the paths of Venus or Bacchus or both. Without 
such an occurrence the preceding dilatation may have produced a 
temporary swelling of the mucosa, which readily subsides. The 
physician, when such an impediment presents, contents himself 
by dilating as much as possible without producing any discomfort. 

4. When a spongy mucosa, as shown by blood oozing from 
the meatus, a re-awakened hyperesthesia or urethrospasm, com- 
mands the removal of the instrument before the time required for 
the day's dilatation, the latter must then "be abbreviated. 

5. When a dilatation is followed by oozing of blood from the 
meatus, bloody urination, or pain, the subsequent dilatations should 
be increased by but a quarter number at each session. If even this 
slow procedure is still followed by any of, or all, the disturbances 
mentioned, it will be well to substitute flexible bougies for the 
dilator until the use of the bougie no longer produces the objec- 
tionable symptoms. The bougie selected should be five numbers 
Fr. less than the last dilatation. Thus if the number reached by 
the dilator was 25, the bougie to take its place should be No. 20, 
or a size as much smaller as will glide through the urethra easily 
and painlessly. 

While, as a rule, the increase of dilatation at each session of 
one-half number Fr. may not be interrupted, this increase should 
never be obtained by force. Nor should the beginner attempt to 
exceed this, even when no resistance whatever presents thereto. 
Those most experienced in dilatations prefer the slow progress, 
because of the greater safety it assures. 

The best practice is to stop dilating at the number last reached 
or at the first slightest resistance, and then at from three to fiv^ 
minutes' intervals to dilate at no more than half numbers, or up 
to slight resistance, until the number desired for the day is at- 
tained. 



DISEASES OF THE URINARY APPARATUS 



427 



Contraindica- 
tions 



Bleeding to quite a considerable extent sometimes follows di- Hemorrhage 
latations, especially in the beginning of treatment. Such a hemor- 
rhage is usually of very short duration; if it threatens to become 
excessive, the penis may be compressed by a bandage until the flow 
ceases. Obstinate cases may require the pressure of a sound within 
the urethra in addition to the bandage. 

As mentioned before, one of the results of dilatations is an in- 
crease of discharge on the morning following treatment, or its re- 
currence if no discharge existed. Oberlaender looks upon this as 
an evidence of the "melting" of infiltrations. However, this may 
be interpreted, the discharge in a case that proceeds in the ordinary 
manner is less in quantity, thinner in consistence, and lighter in 
color at each recurrence, until it ceases entirely. The products of 
inflammation that are carried off in the urine become smaller and 
less in quantity. With these manifestations the general condition 
of the patient improves and local as well as reflex signs of disease 
fade away. 

The limits of dilatation and irrigation are reached when no 
more evidences of disease exist or can be evoked by the tests men- 
tioned previously. 

There are but few conditions in which dilatations are contra- 
indicated. Decrepit persons, those suffering from acute febrile 
conditions, those with large vesical tumors or with genito-urinary 
tuberculosis, or those in whom a severe posterior urethritis per- 
sists, must not be dilated. The last mentioned should be treated 
by irrigations, or by instillations, until the condition of the pos- 
terior urethra ceases to be an impediment to dilatations. (Val- 
entine.) 

If the urethritis depends on the invasion of the crypts, glands 
and follicles, these will have to be slit, curetted, or destroyed by 
electrolysis. Similar treatment is required when diverticula or 
false passages complicate the case. 

In a large proportion of cases of chronic urethritis, disseminated 
areas of granulations are the cause of a persistent discharge; in 
others we find an association with glandulitis and periglandulitis. 
These granulations when of more recent date, readily disappear 
upon dilatation and silver nitrate irrigation. Older granulations, 
especially in the bulbous and prostatic urethra, frequently resist 
such measures, and then topical medication through the urethro- 
scope is indicated. 

The urethroscopic tube should have a caliber between Nos. 26 
and 30, French, in order to well expose the lesions. The solutions 
employed are silver nitrate, from five to fifteen per cent., or sul- 
phate of copper, ten to twenty per cent. These are applied by 



Granulations 



428 



DISEASES OF THE URINARY APPARATUS 



Strong silver 
nitrate solu- 
tions 



Curetting 



Irrigation 
endoscope 



Passive hyper- 
emia 



Chronic 
urethritis in 
women 



Medicated 
bougies 



Cautery 
Fissures 



means of a cotton swab on an applicator. A treatment once a week 
is sufficient. 

This method is more radical and efficient than instillations, 
because the lesions are seen and it is not necessary to depend on 
the very unreliable sensation of pain, and, furthermore, much 
stronger solutions with much, less pain can be employed, while very 
stubborn granulations may be curetted through the urethroscope. 
The insignificant bleeding is checked by compression and the ex- 
posed wound surface touched with twenty per cent, silver nitrate 
solution. 

A decided improvement in urethroscopie diagnosis and therapy 
is represented in the irrigation-endoscope devised by Hans Gold- 
sehmidt, of Berlin. He utilizes the principles of cystoscopy by di- 
lating the urethra around the distal end of the instrument with 
water. Its advantage is particularly obvious in the posterior 
urethra, where by this method details of normal and pathological 
conditions are demonstrated which through other urethroscopes are 
usually not observed, and therefore escape proper treatment. 

Soft infiltrations in the anterior urethra are also" favorably in- 
fluenced by passive hyperemia (Biers method). The constricting 
band is applied at the root of the penis for from thirty minutes tc 
one hour. This treatment should be preceded and followed by an 
irrigation of the urethra with any of the antiseptic solutions enum- 
erated previously. 

Chronic urethritis in women should be treated in the same man- 
ner as in men. Three symptoms in women differentiate the con- 
dition from cystitis, viz., the urine is usually clear with the ex- 
ception of a few shreds ; frequent urination is only complained of in 
the daytime ; and pressure along the anterior vaginal wall is painful. 

Instead of small injections we must rely on medicated bougies, 
using protargol or argyrol in the bacterial stage and astringents, 
like sulphate zinc, alum or ichthyol, in the catarrhal stage. 

Irrigations and dilatations may be employed, and, in stubborn 
cases, topical applications made through the urethroscope. Suit- 
able for this purpose are a two per cent, silver nitrate, or a five 
per cent, argentamin, solution applied all over the mucosa with 
a cotton swab, once in three or four days. 

Hypertrophic patches of the mucosa necessitate linear cauteriza- 
tion. 

Fissures in the urethra which are occasionally responsible for 
the persistence of a chronic urethritis must be cauterized either 
with twenty-five per cent, silver nitrate solutions or more effectively 
with a fine galvano-cautery, as I recommended in 1899. 

Before leaving this chapter a few words might be in place re- 
garding the serum treatment in gonorrheal infection. 



DISEASES OE THE URINARY APPARATUS 



429 



The serum obtained from rabbits which are treated with an 
extract of gonococcus cultures is believed to possess a bactericidal 
and to a certain degree also an antitoxic action. Its inefficiency 
in acute gonorrheal conditions is admitted by those who have done 
much experimental work along this line, but the serum is con- 
sidered efficacious in the treatment of some complications of gon- 
orrhea. Among those considered as amenable are, infection of the 
epididymis, prostate, bladder and the Fallopian tubes, and infec- 
tions of parts outside of the uro-genital tract, such as gonorrheal 
arthritis, iritis and pericarditis. 

This subject, however, is still in the experimental stage and 
lacks clinical support to such a degree that nothing definite re- 
garding its value or the mode of employing it can be stated at this 
moment. 



Serum 
treatment 



INFECTIOUS URETHRITIS OF NON-GONORRHEAL 

ORIGIN. 



Very difficult to manage is the so-called infectious urethritis 
of non-gonorrheal origin, or mixed infection. 

The avenues of infection, if there are any, remain unknown, Etiology 
and the question as to the possibility of transmitting it is still in 
dispute. All the bacteria found in this urethral secretion are known 
to exist in a saprophytic state in a perfectly healthy urethra. The 
appearance of the discharge, both macroscopically and microscopi- 
cally, is different from that of gonorrhea. It commences with or 
without a palpable provocation, such as sexual intercourse, trauma- 
tism, or gonorrheal infection, and does not display an inflammatory 
character. It usually remains confined to the anterior urethra. 

Some cases entirely recover without any treatment, some get Spontaneous 
worse under treatment and others are not influenced one way or the cure 
other. Some are benefited by a treatment based on the action of 
zinc decomposing silver nitrate. There is thus a production of 
silver albuminate and silver chloride which are deposited on the 
mucous lining of the urethra. There is, further, a formation of Combined zinc 
metallic silver, also traces of zinc chloride, and, finally, of zinc 
nitrate, which is perhaps the most effectual factor of all in the 
treatment. To obtain this combined local action, ten to twenty 
drops of a one per cent, solution of silver nitrate are injected in 
the urethra. Immediately afterward a sound made of metallic 
zinc (No. 20 Fr. scale) is inserted. This sound should be held in 
the urethra for a minute or two, until the chemical reaction be- 
comes evident by the pain experienced and by the black discolora- 
tion of the vaseline with which the instrument has been lubricated. 



and silver ni- 
trate treatment 



430 DISEASES OF THE URINARY APPARATUS 

In two minutes this black stain shows that the silver-zinc reaction 
has occurred, and the sound is then withdrawn and should be 
cleansed at once after removal. It may be rubbed with potassium 
iodide until it has reassumed its natural color. It loses its polish 
soon and occasionally has to be sent to be repolished. 



CHAPTER VII. 

DISEASES OF THE MOUTH AND UPPER AIR 

PASSAGES. 

Nearly all the diseases of this region of the body call for topical 
and surgical treatment. A few of the more acute varieties, es- 
pecially those that are complications or part phenomena of gen- 
eral constitutional or infectious diseases, however, belong to the 
province of the internist. The more chronic disorders that are 
accompanied by advanced anatomic changes (hypertrophies and 
atrophies, deformities, abscess, ulcer formation, etc.) should be 
treated by special surgeons alone. Whereas the latter should by 
all means be competent general practitioners, it is nowadays not 
necessary nor, for that matter, possible, for the general practi- 
tioner to be a competent specialist. It is, in fact, almost more 
important that the latter should recognize his limitations in this 
direction, than that he should attempt without adequate training to 
encroach upon the domain of the skilled, experienced specialist. 
It is due precisely to failure on the part of the gen- 
eral practitioner to recognize these limitations that there 
is so much promiscuous, uncalled-for, and generally harmful 
spraying and applying, cutting and cauterizing about the nose 
and throat. 

The diseases of the mouth and upper air passages that the in- 
ternist is frequently called upon to treat, either because their on- 
set is very acute or because they accompany various general dis- 
orders, are the different forms of stomatitis, acute rhinitis, includ- 
ing hay fever and pseudo hay fever, pharyngitis, acute tonsilitis and 
acute laryngitis. The treatment of these disorders alone, therefore, 
will be discussed in this chapter. 

DISEASES OF THE BUCCAL CAVITY. 
STOMATITIS. 

Stomatitis complicates a variety of infectious diseases, gastro- Causes 
intestinal and hepatic disorders, cachexias and anemias, certain 
metabolic disorders as diabetes, the uric acid diathesis and aceto- 



432 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 



Prophylaxis 
in acute infec- 
tious diseases 



Mouth washes 



Glycerin 



Prophylaxis in 

cachetic 

conditions 



nemia, the hemorrhagic diathesis. In children during the period 
of dentition, and especially in bottle-fed infants and children 
with rickets, mouth disorders are common. Finally, in all un- 
conscious states the mouth is apt to become diseased; the stoma- 
titis, in the latter instance, being due in great part to deficient 
salivary excretion and the inhibition of masticating and swallow- 
ing movements, causing the mouth to become dry and prepar- 
ing a particularly favorable nidus for the development of bacteria 
and fungi about the gums, the mucous lining of the mouth and 
the tongue. 

In the acute infectious disorders it is particularly important 
to prevent the development of stomatitis, so that the patients 
during convalescence may not be hindered from eating on account 
of soreness of 'the buccal cavity. The prophylactic measures that 
must be employed in infectious and in comatose states are the fol- 
lowing: In order to induce swallowing, to promote the flow of 
saliva and to prevent cracking of the tongue and lips, the mouth 
should be washed out every two or three hours with a linen rag 
dipped either in a saturated solution of boric acid, or a three per 
cent, bicarbonate of soda solution, or a two per cent, solution of 
chlorate of potash. The latter remedy should not be used if the 
kidneys are affected. In patients who are altogether unconscious 
the tongue should be painted with glycerin, or boric acid in glyc- 
erin in the proportion of one part of boric acid to four parts 
of glycerin, and so much should be applied that a portion 
of the glycerin trickles down into the pharynx. Ice pills 
should be inserted into the mouth or teaspoonful doses of lem- 
onade poured in at frequent intervals. In order to force swal- 
lowing movements, pressure may be exerted upon the base 
of the tongue. On the lips glycerin should not be used because 
it is too hygroscopic. Here vaseline or lanolin are the prop- 
er applications. If all these measures are carefully carried out 
a sore mouth will rarely develop, even in so protracted a disease 
as typhoid fever. 

In chronic cachectic conditions, in sufferers from the hem- 
orrhagic diathesis, in diabetes, the following mouth wash is very 
useful : 



B 



Biborate of soda, 
Menthol water, 
Distilled water, 
M. Sig. Mouthwash. 



30 gm. 
150 cc, 
950 cc. 
— (Ortner.) 



Of this mouth wash a teaspoonful in half a glass of water 
should be used as a cleansing solution after each meal. 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 433 

A useful prescription for the excessive fetor in diabetes has Fetor 
been given on page 218. The following astringent wash is also 
very useful, particularly if there is a tendency to bleeding from the Bleeding gums 
gums: 



9 

Thymol, 
Benzoic acid, 


35 gm. 
3 gm. 


Tincture of eucalyptus, 
Absolute alcohol, 


15 cc. 
100 cc. 


Peppermint oil, 


20 drops 



M. Sig. Mouthwash. A teaspoonful in half a 
glass of water should be used as a wash or gar- 
gle. — (Miller.) 

Another useful mouth wash in cases of bleeding gums is the 
following : 

Thymol, 0.1 

Spirit melissae, 30.0 

Tinct. myrrhae, 

Tinct. calam., . aa 20.0 

M. S. 15 drops in a quarter of a glass of water. 

In all forms of stomatitis, too hot, too cold, too hard or rough 
articles of food, spices, strong alcoholic beverages, and also tobacco 
should be carefully avoided. 

If the mouth disorder is once established the treatment differs Five varieties 
somewhat according to the character of the stomatitis. For prac- °* stomatitis 
tical purposes it is convenient to distinguish five varieties. 
First, simple catarrhal or erythematous stomatitis; second, aph- 
thous (follicular or ulcerative) stomatitis; third, thrush (stoma- 
titis due to oidium albicans) ; fourth, gangrenous stoma- 
titis (noma, cancrum oris) ; fifth, mercurial stomatitis and 
ptyalism. 

In the simple catarrhal form the measures described under Treatment of 
prophylaxis should be employed for the sake of promoting cleanli- h a j form 
ness and antisepsis of the mouth. At the same time any under- 
lying constitutional, gastro-intestinal or hepatic disorder should 
be treated. No special local treatment is required. 

In the ulcerative or aphthous form each ulcer should be touched Treatment of 
with a stick of silver nitrate, or cauterized with a galvano-cau- ap^hou^form 
tery or a Paquelin. The best liquid application in the ulcera- 
tive form is a mixture of potassium chlorate in glycerin in the 
proportion of one to two. Potassium chlorate is a particularly 
useful remedy in the ulcerative form, but should be used 



434 



DISEASES OE THE MOUTH AND UPPER AIR PASSAGES 



Treatment of 
thrush 



Treatment of 
noma 



Treatment of 

mercurial 

stomatitis 



Potassium 
chlorate 
Peroxide of 
hydrogen 



carefully in the aphthous, for, in the latter, it increases the pain. 
If kidney disease is present it should never be used. Potassium 
is excreted in part through the saliva, so that it usu- 
ally grants a prolonged local effect in the mouth. A one 
per cent, sodium salicylate solution, or a one to one thousand 
permanganate of potash solution, may also be used for washing 
out the mouth and touching up the ulcers. If the mouth is 
very sore and painful a few drops of opium tincture or cocaine 
may be added to the solutions. A very useful preparation is the 
following : 



% 



Salicylic acid, 

Cocaine muriate, 

Glycerin, 

Water, 

M. Sig. : For local use. 



1.0 

0.1 
10.0 
10.0 



Thrush is usually preventable if rigid cleanliness of the mouth 
is maintained. In nursing children particular care should be 
exercised to have the nipples clean. Gastro-intestinal disorders 
should be carefully treated and corrected. The best local appli- 
cations are potassium chlorate in a two per cent, solution, or 
potassium permanganate in a one pro mille solution. These are 
best applied on rags that should be rubbed against the 
affected areas in the mouth. Internally, resorcin, one to one hun- 
dred, in teaspoonful doses, two or three times a day, is 
said to exercise an inhibitory effect upon the development of 
thrush (Baginsky). 

Gangrenous stomatitis is a very dangerous complication and 
one that always calls for energetic local treatment. The gan- 
grenous areas should be destroyed either by a galvano-cautery or 
a Paquelin cautery, or by the application of nitric acid or silver 
nitrate in stick form. If the line of demarcation does not form 
within a day or two an artificial line of separation should 
be produced by the use of these caustics and the gangrenous areas 
excised. 

Mercurial stomatitis can generally be prevented by careful 
mouth asepsis carried out as described under prophylaxis. Cer- 
tain individuals, however, seem to have a peculiar susceptibility 
to mercury and become salivated upon the exhibition even of very 
small doses. As soon as the first evidence of stomatitis (usually 
soreness about the gums) becomes manifest, the administration 
of mercury should at once be stopped. 

Two remedies are particularly useful in the fully developed 
form, namely, potassium chlorate and peroxide of hydrogen. The 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 435 

former should be "used in a mouth wash in a two or three per cent, 
solution, or a tooth brush may be dipped into powdered chlorate of 
potash and the teeth and gums energetically brushed with it. 
Peroxide of hydrogen should also be given in the strength of 
about two per cent. As the commercial preparations contain about 
10 per cent., a teaspoonful to one-third of a glass of water ap- 
proximates the proper concentration. 

If mercurial ulcers develop they should be treated with a silver Atropine 
nitrate stick, or should be painted with tincture of iodine or touched 
with chromic acid. Free catharsis should be promoted, sweating 
induced, preferably by hot bathing, and the patient should be in- 
structed to drink plenty of water. Internally, atropine in one-two- 
hundredth grain doses given three times a day often beneficially 
influences mercurial stomatitis. 

GINGIVITIS. 

Internists in general pay too little attention to gingival lesions Significance 
as a local symptom and dentists, as a rule, fail to search conscien- ° glnglvl 1S 
tiously for the underlying systemic causes of gingivitis. This is 
unfortunate because on the one hand a careful study of the gums 
often leads to the early recognition of certain obscure metabolic dis- 
orders, while proper recognition, on the other hand,, of the systemic 
disorders that underlie many cases of gingivitis often points the 
way to a successful therapy of this obstinate and often apparently 
intractable affliction. 

The gums are an end organ supplied by endarteries and with a 
relatively deficient venous backflow ; consequently their nutrition is 
readily interfered with in all disorders involving the peripheral 
arterioles; they are also particularly susceptible to damage when 
the blood carries abnormal toxic products of perverted metabolism. 
They are, further, continuously exposed to mechanical injury and to 
infection by members of the variegated buccal flora that abounds in 
their vicinity. 

In arterio-sclerosis, therefore, in Bright' s disease, in acetonuria, Varieties 
in diabetes, in gout and the so-called uric acid diathesis, in acidosis, 
and in many other similar states the gums are commonly involved ; 
and owing to the accessibility of the gums to inspection and palpa- 
tion a gingivitis is more easily detected than lesions in any of the 
other end organs (kidneys, retina, brain). 

There is nothing characteristic or pathognomonic about the 
gingival lesions that are seen in the different disorders enumerated ; 
and it is not possible, from the appearance or the feel of the gums 
alone to decide whether the gingivitis is due to diabetes or to gout 
or to Bright's disease, etc. 



436 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 



Stages of gingi- 
vitis 



Local treat- 
ment 



A great deal will naturally depend on the stage of the gingivitis, 
on the conformation and condition of the teeth and month, and on 
the character of the month bacteria and fnngi that may happen to 
be present, for all these features determine the kind and the degree 
of secondary infections and mechanical injuries to the gums that 
may have taken place. Thus we may have intense congestion in- 
volving the whole of the gums or merely slightly localized redden- 
ing, we may have lacerated or smooth gums, we may have fungous 
growths covering the gums with large layers of vegetation of vari- 
ous color and outline, or we may have pyogenic infection of the 
deeper tissues or only of the surface along the margin of the dis- 
eased gums, and finally we may have widespread destruction by 
necrosis and gangrene. 

I do not think that in the majority of cases local treatment of 
these lesions is of much value unless the underlying systemic cause 
is at the same time attacked. All the measures that are actually 
employed in stomatological practice essentially amount to promot- 
ing cleanliness, i. e., asepsis of the tissues and cavities surrounding 
the gums, removing foul discharges and correcting mechanical con- 
ditions about the teeth that can further injure the gums and keep 
up irritation. Such treatment is, of course, of much value in pre- 
venting disagreeable consequences, but it is by no means curative in 
the vast majority of the cases of gingivitis that come under observa- 
tion. Here the treatment of the underlying systemic disorder alone, 
as described in other chapters, leads to the goal. 



TONSILLITIS. 



Classification 



Abortive 
ment 



treat- 



The mucous lining about the orifices of the tonsillar crypts 
may become involved in any catarrhal state of the mouth or upper 
air passages, or the crypts alone may be attacked (lacunar or follicu- 
lar tonsillitis) or the whole gland, including its adenoid tissues, 
may be diseased (parenchimatous tonsillitis), or the infection may 
be suppurative in character (tonsillar or peritonsillar abscess) . The 
treatment of these different forms does not vary materially. In the 
suppurative variety, of course, surgical evacuation of the pus be- 
comes necessary. 

Upon the onset of the first symptoms the bowels should be 
thoroughly evacuated, probably best by the use of ten one-tenth 
grain doses of calomel given at ten minute intervals, followed by a 
tablespoonful of magnesium sulphate in. water. The diet should 
be non-irritating to the throat, i. e., should contain no rough or 
hard particles nor spices, nor should it be too hot. 

Internally tincture of aconite, in drop doses, should be given at 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 437 

two hour intervals throughout the attack. The most useful rem- Aconite 
edies for internal use, possibly owing to the intimate relationship 
of tonsillitis to certain forms of rheumatism, are guaiac and the 
salicylates. Guaiac is useful both internally and locally, so that its 
administration in lozenge form is especially appropriate in this dis- Guaiac and 
ease. For internal use the tincture of guaiac may be given in table- sa lcy a es 
spoonful doses in milk, several times a day. Sodium salicylate is 
best given as salol in five to ten grain (0.3 to 0.6 gm.) doses, or in 
combination with some alkali, for instance, as ten grains (06. gm.) 
of sodium salicylate with ten grains (0.6 gm.) of sodium bicar- 
bonate in some simple syrup. This quantity should be administered 
every two hours during the first two days, then every four or five 
hours throughout the course of the disease. 

The local treatment consists in the application of cold exter- 
nally either by means of a Priessnitz compress, i. e., a linen cloth Local treat- 
wrung out of cold water and covered with flannel or, better still, 
by means of a Leiter coil (see index) through which ice water is plications 
flowing. Leeching or blistering the neck are rarely necessary and 
usually very disagreeable to the patient. Painting the neck with 
iodine occasionally helps, but this form of counter-irritation is in- 
ferior to the use of the Priessnitz compress. Sometimes cold ap- 
plied to the neck is very objectionable to the patient; heat may then 
be applied either by means of hot cloths frequently renewed and 
covered with oiled silk or by means of linseed, oatmeal or bread 
poultices. Cold is, however, always more effective in modifying the 
course of the disease than heat. 

The tonsils themselves should be treated by means of gargles or 
by direct applications to the affected glands. The different gargles Internal appli- 
should be used as follows : A small quantity is taken into the mouth, catlons 
the head thrown back, the nose closed with the fingers and thumb, 
the mouth opened and a swallowing movement attempted. The fol- 
lowing gargles are useful : A teaspoonf ul of alum dissolved in half Gargles 
a pint of water, to which is added a teaspoonful or two of some 
flavoring syrup ; or a two per cent, solution of potassium chlorate ; or 
again, the following: 

Salicylic acid, 1.0 gm. 

Glycerin, 1.0 cc. 

Carbolic acid, 1.0 cc. 

Water, 100.0 cc. 
M. Sig. : For local use. 

If there is pain a gargle of equal parts of lukewarm milk and 
water to which are added twenty drops of tincture of opium is very 
soothing. 



438 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 



Sodium car- 
bonate 

^mmoniated 
tincture of 
guaiac 

Inhalations 



Sprays 

Evacuation of 
pus by incision 



Indications for 
surgical treat- 
ment of ton- 
sillitis 



If the tonsils are very much swollen, or if they are very pain- 
ful, gargling is difficult and disagreeable. Here direct applications 
to the tonsils are useful. Dry sodium bicarbonate may be rubbed 
directly upon the tonsils with the fingers, or the tonsils may be 
painted or swabbed with ammoniated tincture of guaiac. 

Inhalations through a steam inhaler of a one per cent, solution 
of sodium bicarbonate to which are added a few drops of tincture of 
opium; or spraying the tonsils with a solution of five grains of 
menthol in an ounce of albolene, are soothing measures. If there 
is much mucus from complicating pharyngitis, then ice cold lemon- 
ade sucked through a straw frequently aids in expelling it. 

If suppuration becomes established then nothing in the nature 
of lozenges, inhalations, sprays or local application should be used. 
Here evacuation of the pus by incision becomes necessary. The in- 
dications for the surgical treatment of tonsillitis are the following:* 

"First. Never to inflict unnecessary pain by useless scari- 
fication of the surface of the tonsils undergoing general inflam- 
mation. 

"Second. Never to make deep incisions unless there is almost 
certainty of advanced suppuration. The instrument for making the 
incision should be a curved, pointed bistoury with not more than 
one inch of cutting edge, and the cut should be made from with- 
out inwards, so as to avoid the not impossible risk of injuring the 
artery. 

"Third. To recommend removal, on subsidence of the attack, 
of all tonsils chronically enlarged and liable to quinsy. 

"Fourth. To remove the tonsils as soon as they become suffi- 
ciently enlarged, in those cases of recurring quinsy in which there 
is not chronic enlargement, but in which the tonsil though diseased 
is too small for excision except on recurrence of the acute inflamma- 
tion. By this means, the present attack is at once cut short and the 
chance of further recurrence is avoided." 



DISEASES OF THE NOSE AND THROAT. 



ACUTE RHINITIS AND PHARYNGITIS. 

Catarrh of the nose and pharynx can fitly be discussed together 
because both these regions are commonly affected simultaneously 
or consecutively, and because the general treatment of acute rhinitis 
and pharyngitis is in all essentials identical. 

Catarrh of the upper air passages is rarely produced by direct 
irritation of the mucous linings of the nose and throat, although 



*Quoted from Lennox Browne. 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 439 

what may be called chemical forms of catarrh occur. The treat- 
ment of the latter form, when the catarrhal condition is once fairly 
established, does not materially differ from that of other forms that 
are due to constitutional causes. 

The most common cause of catarrh of the upper air passages is Causes 
exposure to cold. The nose and throat are a locus minoris resisten- 
tia, partly on account of their exposed condition and partly owing 
to the fact that they are chronically in a state of irritation from the 
inhalation of dust or tobacco smoke, from contact with alcohol, hot 
foods, spices, or from irritation by excessive use of the voice. More- 
over, there is frequently present in these passages a condition of 
passive hypermia due to abdominal plethora and tympanitis 
induced by errors of digestion and liver disorders, gastroptosis and 
chronic constipation; or due to the wearing of tight collars and 
neck bands. Inasmuch as the blood vessels of these parts are, more- 
over, especially susceptible to reflex vaso-motor influences that may 
originate in many different parts of the body, it is not surprising to 
find the nose and throat particularly liable to inflammation as soon 
as the body is exposed to any influence as, for instance, sudden tem- 
perature changes, that tasks the adjusting powers of the vaso-motor 
system. 

It is a well known fact that, normally, exposure of any part Action of ex- 
of the body to cold produces, first, a tetanic contraction of the posure ° c0 d 
capillaries of the exposed area ; second, a reactive dilatation beyond 
the normal calibre of the blood vessels; third, a restoration of the 
vessels to their original calibre. Unless the vaso-motor apparatus 
is functionating in an altogether normal manner, the primary con- 
traction may not occur at all or it may occur promptly, but last too 
long. In either case the secondary dilatation, which fulfills the pur- 
pose of carrying an increased amount of blood to the exposed por- 
tion and hence maintaining its temperature, does not take place 
and the first stage of inflammation is produced. This effect is fre- 
quently exercised in the nose and throat and a catarrh produced in 
this way. Besides, cold affecting certain remote regions of the 
body, especially the feet, the back of the neck and the region between 
the shoulder blades, by a peculiar reflex mechanism that is not well 
understood, readily deranges the vascular supply of the mucous 
lining of the upper air passages and again catarrh is the result. 
Hence, as is well known, a draft about the feet, the back of the 
neck or between the shoulder blades, in susceptible subjects, rapidly 
produces congestion of the nose and the throat, in other words, a 
"cold in the head." 

In order to counteract this tendency to catch cold, the various Prophylaxis 
causes that determine it must be attacked. An intelligent and effi- 
cient prophylaxis can here be instituted by removing, primarily, 



440 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 



local causes of chronic irritation and, next, by "hardening" the 
organism with an unstable vaso-motor system against abnormal re- 
actions to cold. 

The first condition can be fulfilled by eliminating, as far as that 
is possible, all the factors that have been enumerated above and 
that are known to produce irritation of the nose and throat. Here, 
too, the correction of deformities, the removal of hypertrophies, 
adenoid tissue, etc., must be regarded as a useful prophylactic 
measure. 

"Hardening" The "hardening" process must be carried out carefully and with 

due consideration of individual peculiarities. It should properly 
begin in infancy, and babies from the first weeks of life should be 
accustomed to the use of cold water. In adults suffering from fre- 
quent nasal catarrh it is never safe to begin at once with cold 
sponging or bathing, so that the best plan, especially in weak indi- 
viduals, and in old subjects, is to begin with dry rubbing of the skin 
carried on for two or three minutes every' morning. Later alcohol 
may be employed to rub the surfaces of the body, then warm and 
lukewarm water and still later cold water. The best way to accus- 

Cold bathing torn weakly individuals to cold water is to place them into a warm 
bath of about the body temperature and while friction of the body 
is being performed, to gradually cool off the temperature of the wa- 
ter. It will be found that from day to day the temperature can be 
reduced a few degrees without discomfort to the patient until, final- 
ly, cold water can be employed from the beginning. Warm baths 
alone never harden. Strong and healthy individuals, in whom the 
reaction to cold is very energetic can, of course, with impunity be- 
gin at once with the use of cold sponging or cold plunges even in 
the coldest weather. Sea bathing, provided the individuals do not 
stay in the water more than two or three minutes, that is, until the 
first reaction appears, is also useful in strong people. 

Clothing The matter of clothing is of great importance. Most people 

dress too warmly. The underwear should consist of wool, silk or 
flannel, never of linen or cotton. Linen absorbs the moisture quick- 
ly and permits its too rapid evaporation; as soon as it becomes 
wet, it clings to the body and obliterates the layer of warm air be- 
tween the skin and the first garment that is so effective as a non- 
conductor of heat in preventing loss of heat from the body surfaces. 
Wool is a poor conductor of heat and gives off the absorbed water 
very slowly. The fine hairs it contains hold the material at some 
distance from the skin so that a layer of air is always present be- 
tween the skin and the wool. Its rough texture, moreover, causes 
some friction and passive hyperemia of the skin, which is grateful 
to the patients and renders them less liable to catch cold when they 
pass from a warm room into the cold air. Silk and flannel do not 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 441 

absorb moisture so well as wool, but they are very poor conductors 
of heat and as they do not irritate the skin they do not produce quite 
so much perspiration as wool. Chest protectors and back protec- 
tors and mufflers should be eschewed. The throat can be accus- 
tomed to exposure to cold as well as the face. The most dangerous 
form of wrap that can be worn around the throat is, of course, fur ; 
for it produces profuse sweating without absorbing any of the 
moisture and hence favors great radiation of heat wherever worn. 

The temperature of the living room should vary but little from The room tem- 
sixty-five degrees Fahrenheit. The individual who is susceptible to 
catching cold should accustom himself to sleep in a cold room, pref- 
erably wearing a flannel night-dress and a night-cap to protect 
himself from drafts, and should keep warm by using plenty of cov- 
ers, sleeping between flannel sheets if necessary.* 

All the measures enumerated above are particularly useful if 
there is a congenital predisposition to catching cold, or if such a 
predisposition has been acquired by frequent attacks of catarrh, or 
after some infectious disease. In many individuals a general neu- 
rasthenic or hysteric condition will be discovered with abnormal sen- 
sibility of the nervous system, or there may be chronic anemia that 
must be corrected, for in all these cases there is apt to be a perver- 
sion of normal vaso-motor reactions that must be incriminated with 
producing an abnormal tendency to react by nasal or pharyngeal 
catarrh to exposure to sudden temperature changes. 

TREATMENT OF THE ACUTE ATTACK. 

Upon the appearance of the prodromal symptoms such as head- Abortive treat- 
ache, a feeling of fullness in the frontal region, a little chilliness or ment 
fever and oozing of a clear fluid from the nose, with conjunctival 
irritation, it is occasionally possible to abort the attack by the use 
of camphor, opium and atropine. It is always worth while to at- Camphor 
tempt this abortive treatment by giving three drops each of the Opium 
tinctures of belladonna and opium in half an ounce of camphor wa- Atr °P ine 
ter, at three hour intervals, for three or four doses. In addition to 
this internal medication the patient should take a hot mustard foot Foot baths 
bath and apply a mustard plaster to the back of the neck. In the 
evening before retiring five grains of Dover's powder with three Dover's pow- 
grains of quinine and three grains of aspirin should be administered d ? r and d qui " 
in capsule, together with a glass of hot lemonade containing two aspirin 
tablespoonfuls of whisky; the patient should go to bed and be cov- 
ered with woolen blankets until profuse sweating is produced. 

It is very difficult to abbreviate the attack after the catarrh is Treatment of 
once fully established. After the first attempt at aborting the at- attack StabliShed 



♦See also Open Air Treatment of Tuberculosis. 



442 



DISEAS3 



i£ THJi MOUTH AND UPPER AIR PASSAGES 



Symptomatic 
treatment 



Menthol and 
albolene 

Cocaine 



Adrenalin 



tack by sweating has been made it is useless to try to influence the 
duration of the disease by further diaphoresis. Symptomatic re- 
lief may, however, be secured by using a mixture of one part of 
menthol to ten parts of chloroform and placing a few drops of this 
solution into the hand and sniffing the vapors at frequent intervals. 
It is also well to thoroughly wash out the nose two or three times a 
day with some alkaline solution, such as the following : 

Bicarbonate of soda, 0.65 (10 gr.) 

Borate of soda, 0.65 (10 gr.) 

Water, 96.00 ( 3 oz.) 
M. S. Nasal wash. 

A spray containing five grains of menthol to an ounce of albo- 
lene (0.3 to 32) is always very grateful in relieving the sense of 
fullness and the headache. Cocaine, which should be used very 
carefully in the fully developed attack, may occasionally serve a 
useful purpose if it is insufflated in the form of a powder in com- 
bination with menthol. A useful preparation of this kind is the 
following : 

Menthol, 

Cocaine, of each, 0.3 (gr. 4=y 2 ) 

Zinc sozoiodate, 

Boric acid, of each, 10.0 (3 2y 2 ) 

M. Sig. For nasal insufflation. 

Adrenalin, in 1 to 1,000 solution, may also be employed locally 
to give relief. 

All these remedies, recommended for local use, should be used 
only if it becomes necessary to remove excessively distressing sub- 
jective symptoms for the time being; they should not, however, be 
given too energetically in any case, for their violent vaso-constrictor 
action gradually produces paralysis of the vaso-motor nerves, with 
permanent dilatation and serious injury to the nasal mucosa, lead- 
ing in its ultimate consequences to a prolongation of the acute at- 
tack and the establishment of sub-acute or chronic catarrhal condi- 
tions within the nose. 



Definition 



Hay fever and 
pseudo hay 
fever 



CORYZA VASOMOTORIA AND HAY FEVER. 

Vaso-motor coryza is distinguished from catarrhal rhinitis by 
the fact that the secretion always remains watery and never becomes 
purulent. To this category of rhinitis belongs hay fever and pseudo 
hay fever; the former being produced chiefly by the pollen of 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 443 

Ambrosia artemisi folia; the latter by a variety of other floating 
particles of vegetable origin. Vaso-motor coryza usually affects 
neurotic individuals. After exposure to a draft they suddenly begin 
to sneeze violently while a profuse amount of clear watery fluid 
pours from the nose. The attack is usually of short duration. Oc- 
casionally, however, unless rapidly aborted, it leads to true catarrhal 
rhinitis. To abort the attack one-twenty-fourth grain of morphine Abortive 
with one-two-hundredth grain of atropine should be given every ^f atI ?® nt 
two hours for four or five doses. Local applications do no good atropine 
whatsoever. 

The treatment of hay fever and of pseudo hay fever is a very Prophylaxis of 
ungrateful task when the attack is once established. An intelligent ay * ever 
prophylaxis, however, may aid very much towards preventing the 
recurrence of attacks of hay fever, or at least towards rendering the 
seizures less severe and less protracted. In the first place the mu- 
cous lining of the nose must be carefully treated during the winter, 
hypertrophies, varicose veins, deformities, etc., being corrected. 
More important than this, however, is the treatment of the under- 
lying neurotic, i. e., neurasthenic or hysteric, temperament. Here, 
hydrotherapeutic measures, a course of arsenic or strychnia or 
phosphide of zinc, and all the measures described in detail in the 
Section on Gastric Neuroses have an important place. Sufferers 
from hay fever, as is well known, obtain the greatest relief, or even 
complete immunity from attacks, by a change of climate. Most 
mountain climates and the shores of Lake Superior, Lake Huron 
and the northern shores of Lake Michigan enjoy a well merited 
reputation as hay fever resorts. 

Symptomatically, in order to reduce the violent coryza, the con- Opium and 
junctivitis and the asthma in patients who cannot go away, opium Dellad onna 
and belladonna, in two or three drop doses of the tinctures, may be 
given three or four times a day. Often small doses of atropine, one- 
two-hundredth grain, are useful, also given three or four times a 
day. The menthol-cocaine mixture, described on page 442, may be Menthol-cam- 
inhaled, or smelling salts of the following formula be used with phor 
considerable relief to the patient: 

Carbolic acid, 30 drops 

Ammonium carbonate, 1 ounce 

Charcoal powder, 1 ounce 

Lavender oil, 20 drops 

Compound tincture of benzoin, y 2 ounce 

M. Sig. Smelling salts. — (Lennox Browne.) 

Sprays of adrenalin, morphine, salicylic acid, cocaine, capsicum, Sprays 
etc., have all been recommended, but their effect is very transitory 



444 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 



and, as a rule, injurious to the nasal capillaries, especially if used 
continuously. Their use had best be eschewed altogether or reserved 
for emergencies when it becomes necessary to grant temporary 
relief. 
Pollantin The isolation by Dunbar of a poisonous substance capable of 

producing typical attacks of hay fever, in suitable subjects, from 
the pollen of various plants and the preparation from such pollen 
of an antitoxic serum by the immunization of horses (pollantin), 
coupled with a series of rather favorable results obtained in the 
beginning, engendered the hope that a specific remedy had been 
discovered against this exceedingly distressing ailment. Unfortu- 
nately, to judge from the numerous reports that are found scattered 
through the literature of the last few years, these expectations have 
not been verified and it appears that pollantin has only a very slight, 
if any, therapeutic effect in hay fever. Change of climate, care- 
ful attention to the toilet and hygiene of the nasal passages, and all 
measures that are directed towards preventing the entrance of the 
crude pollen into the nasal passages, are effective prophylactic meas- 
ures. The attacks themselves are amenable only to symptomatic re- 
lief by the use of various vaso-constrictor sprays, in which adrenalin 
undoubtedly occupies first place. Systematic plugging of the nos- 
trils with greased cotton, if persistently carried out, occasionally 
prevents the attacks, but it is questionable whether the remedy with 
all the discomfort and trouble it entails is not possibly worse than 
• the disease. 

If pollantin is to be used at all, it is best instilled into the eye 
in the dose of several drops, and also applied in the same dose to the 
nasal mucosa. 



EPISTAXIS. 



Epistaxis of 

mechanical 

origin 



Epistaxis of 

constitutional 

origin 



Nose-bleed is an important symptom of manifold origin that 
the internist is frequently called upon to treat. Those forms of 
epistaxis that are due to mechanical injury of the blood vessels of 
the nasal mucosa of necessity call for topical or surgical treatment. 
To this category belong cases of epistaxis that follow trauma, espe- 
cially fracture of the base of the skull, rupture of the sinuses, etc. ; 
epistaxis occurring as a complication of tumors, malignant or other- 
wise, of the nose or its accessory cavities whose surfaces within the 
nose undergo ulceration with resulting erosion of superficial arter- 
ies; and epistaxis from ulcers of the nasal cavity due to syphilis, 
lupus and other causes. 

In addition to this mechanical form there are important forms 
of epistaxis that are due to constitutional causes. In the first place 



DISEASES OE THE MOUTH AND UPPER AIR PASSAGES 445 

any of the manifestations of the hemorrhagic diathesis, notably 
hemophilia, scurvy and purpura, as well as any of the severe anemias 
and leukemia, can produce hemorrhage from the nose.. Here the 
hemorrhage is rarely profuse but generally consists of slow and con- 
tinuous oozing with the formation of large clots and hematomata. 
In most of these cases one must assume that diapedesis of blood 
occurs through vessel walls weakened and rendered permeable to 
blood plasma and corpuscles by nutritional disorders of their tis- 
sues ; now and then these degenerative changes produce fragility and 
rupture of arterioles with more profuse bleeding. 

To the same class undoubtedly belong those forms of nasal Epistaxis in 
hemorrhage that occur as a part phenomenon of various infections intoxications* 1 
and intoxications. Thus in typhoid fever, in most of the exanthe- 
mata and in yellow fever, nose-bleed is common ; in hepatic cirrhosis 
and acute yellow liver atrophy, also phosphorus liver, in gout and 
in diabetic acidosis epistaxis may occur. The exact explanation 
of this phenomenon is still forthcoming, presumably, however, one 
is dealing with degenerative processes occurring in the vessel walls 
superinduced by the action of circulating bacterial toxins or of 
poisonous products of perverted metabolism. 

A third variety of cases of epistaxis occurs in diseases of the Epistaxis in 
cardio-vascular apparatus accompanied by high arterial pressure dise _ase of the 
with fragility of blood vessel walls or profound venous stasis as, for lar apparatus 
instance, in arterio-sclerosis, in syphilitic arteritis, chronic alco- 
holism, and lead-poisoning. 

In valvular diseases of the heart in the stage of decompensa- 
tion, or in tricuspid lesions before the balance of compensation is 
broken, hemorrhage from profound venous stasis about the nasal 
mucosa is apt to occur. In this group of cases hemorrhage from 
the nose rarely takes place spontaneously but is usually superin- 
duced by some straining effort; so that hiccough, bronchitis, em- 
physema, nausea, vomiting from whatever cause, consti- 
pation and all other disorders that force the patient to strain must 
be considered determining causes of nose-bleed in predisposed 
subjects. 

Finally there is an interesting class of cases of epistaxis re- Epistaxis and 
lated to disorders about the sexual apparatus. It is well known orders dlS " 
that irritation of the sexual sphere can produce turgescence of 
the corpora cavernosa of the turbinates; that inversely stimuli 
applied to the nose influence the sexual sphere, so that certain 
odors exercise a peculiarly stimulating effect upon the libido sex- 
ualis; that treatment of the nose, especially cocainization of cer- 
tain sensitive areas, can occasionally exercise a profound effect 
upon dysmenorrhea. It is not surprising, therefore, to find nose- 
bleed occurring not infrequently as a part phenomenon of dis- 



446 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 



Topical treat- 
ment 



Ice compress 
and ice water 
injections 



Cauterization 
of the bleeding 
spot 



Tamponade 



orders of the sexual sphere. Epistaxis is a common accompani- 
ment of excessive masturbation; it is especially frequent 
during the age of puberty in individuals of both sexes and it not 
infrequently accompanies menstruation or takes its place, so that 
it has been characterized in these instances as a vicarious form of 
menstruation. 

To treat epistaxis, especially chronic recurrent or particularly 
obstinate, continuous forms of the disorder, successfully all these 
causative factors must be thought of, the exact etiology determined 
and causal treatment instituted accordingly. 

Epistaxis due to purely local causes, violence, trauma, tumor, 
ulceration, chronic nasal catarrh with erosion of arterioles, calls 
for appropriate topical treatment. In post-operative and trau- 
matic nose-bleed it is a good general rule not to be in too great 
a hurry to stop the nasal hemorrhage by active interference, as most 
cases of traumatic epistaxis have a tendency to become spontane- 
ously arrested, and the hemorrhage is rarely so profuse as to en- 
danger life; with the loss of blood, moreover, the coagulability 
of the blood increases. The simplest measures that should be 
tried, if the hemorrhage does not cease spontaneously within a 
reasonable time, are the application of ice to the outside of the 
nose (pressing a piece of ice against the side of the nose near 
the bridge) and the injection of ice water into the bleeding nasal 
cavity. If possible tampons should be avoided in these cases, 
as they are exceedingly disagreeable to the patient during 
the days they have to remain in place and may cause new 
bleeding from tearing of the clot or cicatrix when they are 
removed. 

If the hemorrhage is very profuse and the patient becomes 
rapidly exsanguinated so that one is justified in assuming that 
an artery has been ruptured or eroded, then every effort should 
be put forward to find the bleeding spot. If the bleeding area can 
be located, after cleansing the nose of blood, it should be touched 
with trichloracetic acid, a stick of silver nitrate, tannin powder or 
a strong solution of hydrogen peroxide or, if necessary, with the 
actual cautery, remembering always that the latter should be re- 
moved while hot, as otherwise the clot becomes adherent to the in- 
strument and may be torn off again. 

If it is impossible to stop the hemorrhage in this way, then 
tamponade of the nose becomes necessary. The application of 
a simple aseptic cotton, or better still, of iodoform gauze, should 
be preferred to the use of cotton saturated with cocaine (5 per 
cent.) or antipyrin (10 per cent.) or ferric chloride solutions; 
especially the latter should be avoided for its styptic effect is slight, 
the clot that is formed is very fragile and, above all, the tampons 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 447 

become very slippery and are apt to drop out. Provided simple Digital corn- 
packing of the nose with cotton or iodoform gauze, combined with 
digital compression from without, do not stop the bleeding, then it 
becomes necessary to ping the posterior nares with a Bellocq canula Plugging of 
according to the methods described in special works on 
disorders of the nose and throat and in text books on 
surgery. 

While these local measures are being applied the general man- General man- 
agement of violent nasal hemorrhage is the following: The col- agemen 
lar or neck-band should be loosened; the patient should not be 
allowed to stoop over and should be put to bed in a semi-recumbent Position 
position with the head high or thrown back. Often holding the 
hands over the head is a useful measure. It may become neces- 
sary to ligate off the extremities with bandages in order to re- 
duce the volume of blood streaming to the head. If the blood Ligating ex- 
pressure falls from loss of blood and the pulse becomes small remitles 
and weak, a hypodermic injection of camphorated oil, 
or of camphor in ether, or of ether alone, must be given for Supporting the 
their analeptic effect. The management of post-hemorrhagic ea 
anemia is fully described elsewhere. (See index.) 

In the other forms of nose-bleed that are not due to injury Treatment of 
or erosion of larger blood vessels in the nose, the following plan terfawfsease 31 " 
of treatment should be adopted: In cases that are accompanied 
by high arterial tension, notably in cases of cardio-vascular and 
renal disease, in syphilitic arteritis and arterio-sclerosis, an ef- 
fort should always be made to discover the bleeding point in 
the nose. In the majority of cases the hemorrhage occurs from 
the septal artery at a spot near the anterior part of the sep- 
tum. In this region spurs are often found, so that here the 
mucosa is often attenuated and foreign bodies can also readily lodge 
and cause local erosions. While every attempt is being put for- 
ward to stop the hemorrhage locally by direct treatment of the 
bleeding spot (see above), by ice water injections, by packing 
with pledgets of cotton or iodoform gauze combined with digital 
compression and the application of ice externally; while the pa- Aconite 
tient is instructed to hold his arms over his head and to follow Veratrum 
the other general rules in regard to position that have been de- 
scribed above; an attempt should also at once be made to lower 
the blood pressure by giving drop doses of the tincture 
of aconite or of veratrum viride every half hour for three 
or four doses, or better still by giving one single dose of three 
to five drops of aconite tincture in water at once, followed later 
by one-hundredth grain doses of nitroglycerin, repeated once Nitroglycerin 
or twice, or by one dose of one grain (0.05 gm.) of ery- ^J7 th - r t ol t 
throl tetranitrate. 



448 



DISEASES OF THE MOUTH AND UPPEK AIR PASSAGES 



Treatment of 
epistaxis due 
to venous 
stasis 



Digitalis 



Analeptics 

Mustard foot 
baths 

Hydrastis 
Cotarnine 



Venesection 



Avoidance of 

straining 

efforts 



Dangers of 
ergot 



If the blood pressure is not high, and if the epistaxis is due to 
simple oozing from congested veins or from rupture of venules 
or capillaries on the surface of the nasal mucosa, and if this ven- 
ous congestion is due to decompensated heart lesions, or tricuspid 
insufficiency without decompensation, then the use of digitalis in 
five drop doses of the tincture, repeated three or four times at one 
hour intervals or, better still, of camphor, ether, ammonia or other 
analeptics, is indicated. Here the patient should sit up 
and place his feet in hot water medicated with mustard, 
about three or four teaspoonfuls to a gallon of water. 

The best internal remedy aside from cardiac tonics is hy- 
drastis in twenty to thirty drop doses of the tincture, repeated 
several times, or as hydrastinine hydrochlorid in doses of one- 
half to two grains (0.03 to 0.13 gm.), in watery solution, by 
mouth or hypodermically. Cotarnine (stypticine) in the dose of 
one-third to one-half grain (0.02 to 0.03 gm.) may be administered 
in the same way. Combined with these measures simple local 
treatment with ice water, digtal compression and, if necessary, 
packing with cotton may be tried. Sometimes, too, venesection 
and the withdrawal of 200 to 300 cc. of blood is a very useful 
procedure. If the bleeding from the nose occurs frequently in 
such cases and if it is generally superinduced by some strain- 
ing effort then all the factors that determine the straining, i. e., 
coughing, vomiting, hard defecation, should be removed and 
appropriate treatment undertaken against any underlying 
chronic respiratory or gastro-intestinal disorder that may be 
present. 

A word of warning may be expressed in this place against 
the use of ergot in nose-bleed. This drug is commonly recom- 
mended for the arrest of hemorrhage anywhere in the body, and 
while it is of marked value in the arrest of uterine hemorrhage, 
it is doubtful whether it is efficacious in epistaxis. I believe it 
does more harm than good in nose-bleed, even in those cases 
in which it is desired to cause constriction of bleeding arteries; 
in all the other cases of nose-bleed in which the hemorrhage 
occurs from bleeding veins and capillaries, or in which the hem- 
orrhage is due to diapedesis of blood through degener- 
ated vessel walls, its use is at least superfluous, for 
ergot usually produces a slight rise of the blood pressure. Ergot, 
moreover produces blood vessel constriction only in certain defin- 
ite areas and the nasal mucosa does not happen to be one of the 
regions in which the drug exercises this effect on the vas- 
cular supply. As a matter of fact I have never been satisfied 
that it acts beneficially in nose-bleed or in pulmonary hem- 
orrhage. 



DISEASES OE THE MOUTH AND UPPER AIR PASSAGES 449 

Opium and morphine and members of the chloral group Opium 
should also always be avoided in treating cases of nasal hem- M °rphine 
orrhage. The temptation to give these remedies is great as the ^ e use( j 
patients are often restless and frightened and one might think 
of giving them sedatives in order to quiet this excitement. 
Opiates, however, reduce the tone of the vaso-motor center in 
the medulla and hence cause vaso-dilation and consequently con- 
gestion, especially about the head. Witness the flushing of the 
face after the exhibition of opiates, that renders them decided- 
ly harmful in hemorrhages from the nasal mucosa. The 
drugs of the chloral group exercise a similar effect, for they 
too produce paralysis of the vaso-motor nerves and induce periph- 
eral congestion. 

The causal treatment of nasal hemorrhage, due to anemia, Causal treat- 
leukemia, various infections, auto-intoxication in hepatic and ™q^s and* CC " 
gastro-intestinal disorders and in poisoning by different drugs is toxic epis- 
in all particulars the same as the treatment of the underlying axis 
disorders and need not be discussed again in this place. It is 
frequently difficult to determine whether the nose-bleed is due 
to the toxemia direct, i. e., to changes in the composition of the 
blood, or to degenerative changes in the vessel walls of the nasal 
mucosa, or to general cardio-vascular changes (high blood pressure, 
venous stasis, etc.) produced by the circulating poisons. 

It is well to remember that occasionally nose-bleed is a useful Epistaxis often 
means adopted by Nature to relieve plethora, especially in indi- a useful oc " 
viduals suffering from stasis due to decompensated heart lesions 
and in subjects of an apoplectic habit. Here the shedding of 
blood from the nose is a safety-valve action and one of Nature's 
means of defense against more serious injury. In such instances 
the physician must frequently exercise his best judgment in 
regard to the advisability of stopping the hemorrhage at once or 
of allowing some blood to escape before endeavoring to arrest 
the flow. If the conditions are such that venesection would 
have been indicated, then no effort should be made to stop the 
nose-bleed too soon. 

By the same sign bleeding the patient from the arm may Bleeding as a 
occasionally be efficacious in forestalling disagreable vicarious prophylactic 
menstruation from the nose. In some of these cases hemorrhoidal ous epistaxis 
bleeding occurs instead of epistaxis, so that if it is desired to 
stop or prevent the nose-bleed, leeches to the anus often accom- 
plish this purpose if leeching is performed immediately before Leeches to the 
and during the time of the menstrual period. Hot vaginal anUS 
douches or a hot sitz-bath; free evacuation of the bowels by a Sitz baths and 
saline laxative; tincture of cimicifuga, in five drop doses, every d uc | menstru-" 
four hours, during the two or three days preceding the expected ation 



450 



DISEASES OF THE MOUTH AND UPPER AIR PASSAGES 



menstruation, pil. aloes et ferri five grains (0.3 gm.) two . or 
three times a day, or pil. aloes et myrrha in the same dose, occa- 
sionally aid in overcoming the amenorrhea and in preventing 
vicarious enistaxis. 



ACUTE LARYNGITIS. 



Abortive 
treatment 



Expectorants 



Cold compress 



Moist atmos- 
phere 



Inhalations 



The prophylactic and internal treatment of acute laryngitis 
is essentially the same as that of acute rhinitis and pharyngitis. 
Upon the first appearance of the prodromal symptoms, sweat- 
ing, mustard foot baths and the combination of quinine, 
Dover's powder and aspirin, with hot whisky lemonade, should 
be given. The bowels should be thoroughly evacuated up- 
on the onset of the attack by the use of calomel given in one- 
tenth grain doses for ten doses in the evening, and 
followed in the morning by a tablespoonful of magnesium sulphate 
in water. 

As soon as secretion becomes established mild expector- 
ants may be given. The following expectorant mixture is very 
useful : 



i» 



Ammonium carbonate, 

Tincture of scilla, 

Compound tincture of camphor, 

Syrup of ginger, 

Infusion of serpentaria, q. s., 

M. Sig. Expectorant mixture. 



5 grains 
10 drops 
15 drops 

1 drachm 

1 ounce 

■ ( Lennox Browne. ) 



A very practical adjuvant to the treatment and one that alone, 
better than any other means, often suffices to bring about quick 
relief and to hasten restitution to normal conditions, is cold 
about the throat applied by means of the Leiter coil or a hand- 
kerchief wrung out of cold water, placed tightly about the throat 
and covered with a woolen or flannel bandage. It may be left on 
over night and renewed again in the morning; or, if the patient 
remains at home, applied several times during the day. 

The atmosphere of the room should be saturated with mois- 
ture from a steam kettle. Inhalations of steam medicated with 
equal parts of a mixture of oil of terebinth, juniper and eucalyp- 
tus, or compound tincture of benzoin, may be used as follows: A 
teaspoonful of the mixture of the three oils, or of the benzoin, is 
mixed with a quart of boiling water in a dish; the patient's head 
and the dish are covered with a thick cloth and the rising vapors in- 



DISEASES OE THE MOUTH AND UPPER AIR PASSAGES 451 

haled deeply for five to ten minutes at a time, three or four 
times a day. Or the inhalations may be made through a pa- 
per cornucopia, the large end of which is held over the 
dish of hot water. Special steam inhalers may also be used to 
advantage and here any of the ethereal oils mentioned above, par- 
ticularly oil of terebinth, the oleum pumilionis, or the oil of 
juniper are useful. In case of severe pain and difficulty in 
swallowing ten to fifteen drops of opium tincture may be added 
to the inhaling fluids. 

In the later stage of the disease when the mucus becomes 
tough and difficult of expectoration^ inhalations through a steam 
vaporizer of a 1 to 2 per cent, solution of common salt, or of 
sodium bicarbonate, are exceedingly useful, and here again the 
addition of a few drops of opium tincture will relieve the sore- 
ness in the throat better than any means that I know of. 

Intra-laryngeal applications are rarely necessary unless there Intra-laryngeal 

,\ b , • .,, , . , -. applications 

is very great hoarseness, or much pain with burning and dryness 

and difficulty in swallowing. A useful laryngeal spray containing 

cocaine and bromide of potash is the following: 

Muriate of cocaine, 0.03 

Bromide of potash, 10.00 

Distilled water, 300.00 
M. S. Spray. 

Better still, however, is the insufflation of a powder consisting Insufflation 
of equal parts of alum and sugar of milk. The latter should, how- 
ever, only be used as an emergency measure to stop hoarseness 
and aphonia in an individual, for instance, who has to use 
his voice for two or three hours despite the existence of laryngeal 
catarrh. 

Symptomatically, the thorough cleansing of the nasal pas- Cleansing the 
sages with an alkaline wash, followed by a menthol and albo- nasal P assa S es 
line spray, as described under Rhinitis, is often followed by good 
effects upon the laryngitis. 



CHAPTER VIII. 

DISEASES OF THE BRONCHI. 

ACUTE TRACHEOBRONCHITIS. 

In acute catarrhal bronchitis there is always, first, hypere- Classification 
mia of the mucous lining of the bronchial tubes followed by de- 
generation of the superficial epithelia, then an outpouring of 
a serous transudate with swelling of the mucosa and narrowing 
of the lumen of the bronchial tubes and, last, loosening and de- 
squamation of the epithelia that have undergone degeneration. 
Clinically, it is convenient to distinguish two stages, viz., what 
may be called a dry and a wet stage, the former being the stage 
of hyperemia, the latter the stage of profuse exudation of serum 
and casting off of degenerated epithelium. The object of the 
treatment in acute bronchitis must be, if possible, to abort the 
attack while it is still in the dry, hyperemia stage, or, if this 
fails, to convert the first into the second stage as rapidly as pos- 
sible. 

Prophylaxis can be exercised merely in rendering the indi- prophylaxis 
vidual less susceptible to temperature changes or other extrane- 
ous influences that determine bronchial catarrhs. Here the 
same rules in regard to clothing, diet, bathing, exercise, etc., ob- 
tains as in the prophylactic treatment of catarrh of the upper re- 
spiratory passages, and I refer to the chapter on these disorders for 
the details. 

Upon the onset of the first signs of bronchial catarrh, viz., Abortive 
a sense of dryness, irritation or pain behind the sternum and treatment 
along the distribution of the larger bronchial tubes, a saline lax- 
ative should be administered and the patient should take a dose 
of three grains (0.2 gm.) of quinine sulphate, and drop doses of 
the tincture of aconite every hour for five to six doses. Hot 
lemonade, with a tablespoonful of brandy or whisky to the tum- 
blerful, should be freely taken. A general hot bath of 100° to 
105° F., provided the patient can go to bed afterwards and sweat 
between woolen blankets, is very useful. Turkish baths, which 
are very popular, are dangerous unless the patient can remain in 
the bath establishment over night. It is rarely necessary to give 



454 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 



The treatment 
of the dry 
stage 



Inhalations 



Bronchitis 
tent 



Opiates 



Atropine series 



Alkalies 



pilocarpine to produce sweat, as the hot bath, with hot alcoholic 
drinks, possibly a ten-grain Dover's powder, suffice to produce 
the desired vaso-dilator and diaphoretic effect. After an 
hour or two of profuse sweating the patient should be care- 
fully dried and put back to bed between dry, warmed linen 
sheets. 

If these measures do not abort the attack, then every effort 
should be put forward to soothe the inflamed mucosa and, at the 
same time, promote outpouring of fluid from the bronchi; in 
other words, to relieve the dryness and hasten the development 
of the second stage. This object can be accomplished by inhala- 
tions, the use of opiates and alkalies internally, and stimulating 
compresses externally. 

Inhalations of physiological salt solution, or of 2 to 3 per 
cent, sodium bicarbonate solution, through a steam inhaler are 
very useful. Instead of using a steam inhaler the patient may 
hold his head, covered with a cloth, over a dish of boiling water, 
to which may be added tincture of benzoin (one drachm to one 
pint), a few drops of opium tincture, or of extract of belladonna; 
the latter especially if the cough or the retrosternal pain is very 
severe. In children the bronchitis tent serves a very useful pur- 
pose. It is constructed by hanging over the bed sheets support- 
ed either by a special rack or by a screen. Within the tent a 
kettle of water is kept boiling by means of an alcohol lamp. 
In this way the child continuously breathes air that is saturated 
with moisture, and a very soothing effect upon the inflamed mu 
cous membrane of the bronchial tubes can be obtained in this 
simple manner. 

Internally some opiate -will generally have to be given to allay 
the cough, preferably morphine, in the dose of one-thirty-sec- 
ond to one-twelfth of a grain, or codeine one-sixteenth to one-fourth 
grams. The numerous other opium derivatives, as heroin, dionin, 
peronin, etc., possess no advantages over morphine and codeine. 
Hyoscyamus, stramonium, belladonna and other members of the 
atropine series are best reserved for the stage of profuse secre- 
tion, for while they act as sedatives and relieve bronchial spasm 
they also check secretion and the latter effect is undesirable dur- 
ing the dry stage of bronchitis. Alkalies, administered in the 
form of citrates, acetates or carbonates of potassium or sodium, 
in doses of ten to thirty grains (0.6 to 2 gm.) at four or five hour 
intervals, in milk or water, or in the form of mineral waters, act 
very beneficially at this stage. It is possible that they are in part 
execreted by way of the bronchial mucosa hence causing some irri- 
tation with outpouring of secretion. Their exact mode of ac- 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 455 

tion is not all understood, but empirically we know that they act 
very beneficially. 

One of the most useful adjuvants to the treatment of this stage Counter-irrita- 
of bronchitis is counter-irritation over the chest, preferably ad- £h^ t ° ver * ° 
ministered by the use of cold compresses. A linen bandage about 
three yards long and six inches wide is dipped into water of room Cold compress 
temperature and thoroughly wrung out. One end of the binder is 
applied to the right axilla, the binder carried across the chest to 
the left shoulder, across the back to the right axilla, across the 
chest to the left axilla, across the back to the right shoulder and 
then to the middle of the chest. A second cross bandage of dry 
flannel is then applied over the first one and the dressing left in 
place until it is dry, which usually requires four or five hours. A 
second wet pack may then be applied, or the skin may be washed 
with alcohol and rubbed dry. It is unnecessary to apply an im- 
permeable oil-silk or rubber dressing over the wet bandage; if 
the binder is to be left on all night the patient may wear a woolen 
shirt rather than a flannel bandage over the cross bandage. Mus- Plaster, cup- 
tard plasters, dry cups, iodine and camphorated oil, are not as ef- P in S» 10 dme, 
fective as this simple means. 

As soon as the dry, hyperemic stage is over and an exudation Treatment of 
of mucus from the bronchial mucosa has begun, then the treat- t e wet sta £ e 
ment becomes radically different. Three main indications must 
now be met, namely, first, to promote liquefaction of the sputa ; 
second, to aid their expulsion; third, to allay excessive coughing 
and to relieve the pain in the chest. 

A number of remedies can be employed to produce liquefaction Liquefaction 
of the sputa. As already indicated above, alkaline or saline wa- of the s P uta 
ters serve this purpose. They should be taken warm at frequent Alkalies 
intervals and in abundant quantities, either alone or mixed with 
milk. 

Probably the most useful remedy in this condition is chloride Ammonium 
of ammonium. It is not improbable that this drug is in part chloride 
excreted via the bronchial mucosa, so that it acts locally as a 
slight stimulus to the bronchial epithelia and produces a reactive 
outpouring of serum ; besides, ammonia salts exercise a stimulating 
effect upon the respiratory centers in the medulla and hence aid 
in the expulsion of the mucus. The dose of ammonium chloride 
varies from five to fifteen grains (0.3 to 1 gm.) and it should 
be given at three or four hour intervals. A very convenient and 
useful way of administering it is in solution in mist, glycyrrhizse 
comp. 

Emetics, given in small doses, produce a copious transuda- Emetics 
tion of bronchial mucus and of saliva. They are all very useful, 
therefore, if the bronchial secretion is tousrh and viscid and thus 



456 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 



Ipecac 



Apomorphine 
Tartar emetic 
Turpentine 



Terpene hy- 
drate 



Terpinol 



Balsams of 
Peru and tolu 
Sodium ben- 
zoate 



Volatile oils 
Copaiba 



Cubebs 
Santal oil 



Strychnia 



difficult of expectoration, but they should never be used when 
the secretion of the bronchial tubes is abundant. Nor should 
they ever be given to sufferers from heart disease or from ca- 
tarrh of the stomach. The most useful members of this group 
are ipecac, most conveniently given in the form of Dover's pow- 
der, five grains, several times a day ; or as syrup of ipecac in one- 
half to one teaspoonful doses; apomorphine, given in doses of 
one-twentieth to one-tenth of a grain (.03 to .06 gm.) ; and 
tartar emetic, in doses of one-thirtieth to one-eighth grain, two 
or three times a day. 

Turpentine is also useful at this stage; it should be given in 
ten to twenty drop doses in a tablespoonful of milk and half a 
glass of milk taken immediately afterwards. If the patients can- 
not take the milk, five to six drops of turpentine may be placed 
upon a piece of bread and butter and the drug taken in this way. 
The milk and the butter prevent the irritating effects of turpentine 
upon the gastric mucosa. Agreeable preparations of turpentine are 
terpene hydrate, which can be given in daily doses of 0.2 to 0.5 
gm., acceptably in dilute alcoholic solution with some simple syrup ; 
terpinol, in three grain doses, four or five times a day, in capsule 
with two or three parts of olive oil. 

The balsams of Peru and tolu are very popular in the treat- 
ment of bronchitis. They all contain benzoin or its derivatives, 
hence sodium benzoate belongs to the same group. Balsams of 
Peru and tolu should be given in an emulsion or as a mucilage in 
doses of five to fifteen grains (0.3 to 1 gm.) several times a day. 
The syrup of tolu is particularly useful as a vehicle for am- 
monium chloride, emetics or opiates, but it contains very little of 
the balsam so that it is itself practically inert. Benzoate of soda 
is generally very useful; it should be given in five to thirty grain 
doses (0.3 to 2 gm.) two or three times a day. 

Certain of the volatile oils, as copaiba, cubebs and santal, may 
also be given at this stage. Copaiba, in the form of the oleoresin, 
in capsule, in doses of ten to twenty drops (0.6 to 1.3 cc.) ; cu- 
bebs also as the oleoresin, in doses of ten to fifteen minims (0.6 
to 1) ; and santal oil in the, same dose, several times a day. Tur- 
pentine and the balsams are apt to irritate the stomach and the 
kidneys and hence they should be administered with care and 
their use discontinued at once upon the appearance of signs of 
gastric or renal irritation. 

In order to aid the expulsion of the mucus strychnia is one 
of the most effective remedies, for it causes contraction both of 
the bronchial musculature and of the large respiratory muscles. 
Strychnia is particularly valuable in cases of bronchitis in which 
much tough mucus accumulates during the night, so that the 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 457 

patients awake with severe dyspnea. Here the administration of 
one-thirtieth, to one-fortieth of a grain of strychnia before go- 
ing to sleep frequently prevents these attacks of nocturnal dyspnea. 
Senega, finally, which may be given in doses of ten to twenty 
drops (0.6 to 1.3 gm.) of the fluid extract, or in the form of the 
syrup of senega, one to two drachms (4 to 8 gm.), may also oc- Senega 
casionally be employed in this stage of bronchitis. 

If the cough is very severe and distressing then it becomes Opium and 
necessary to allay both the irritability of the coughing center morp ine 
and the local sensitiveness in the pharynx. This can best be 
done by small doses of opium or morphine, preferably given in 
combination with atropine or belladonna, especially if there is, at 
the same time, a very active and profuse discharge of bronchial Atropine 
secretion. 

One of the best standard preparations for internal use at this Mistura 
stage is the compound licorice mixture containing opium, anti- glycyrrhizae 
mony, spirits of nitrous ether and licorice as its chief ingredients. 
It should be given in one to two teaspoonful doses, several times 
a day. In order to quiet the local irritation in the throat any Cough syrups 
demulcent or syrup is useful, and here the innumerable cough drops 
drops and cough syrups that are recommended have their field 
of application. 

CHRONIC BRONCHITIS AND BRONCHIECTASIS. 

Chronic bronchitis may develop as a result of repeated at- Causal and 
tacks of acute bronchitis, or it may be a part phenomenon or treatment 
complication of heart lesions, arterio-sclerosis, emphysema, obes- 
ity, gout, chronic nephritis and other disorders. The chronic in- 
flammation of the bronchial mucosa generally yields to appro- 
priate treatment directed towards removing the underlying cause, 
as discussed in the section on these different diseases. If the 
primary affection is irremediable, or if mechanical destruction, 
scil. atrophy of the mucous lining of the bronchi, has occurred, then 
the treatment of chronic bronchitis of necessity becomes sympto- 
matic. The treatment of the different varieties of chronic bron- 
chitis differs somewhat according to the character of the secre- 
tion. From a therapeutic standpoint it is practical to distinguish 
a dry form of chronic bronchitis in which there is very little secre- 
tion; a moist form in which there is very abundant secretion; a 
form in which the exudate is fibrinous and in which casts of the 
bronchial tubes appear, and, finally, a purulent or putrid form 
of chronic bronchitis. 

In all kinds of chronic bronchitis the choice of climate is ex- Climate 
ceedingly important. In the dry variety a moist, warm climate 



458 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 



Mountains 
Seashore 



Hydrotherapy 



Alkaline and 
saline waters 



Sulphur waters 



Medicamentous 
treatment 



Treatment of 
putrid bron- 
chitis 



with the minimum of sudden temperature changes is the ideal, 
whereas in the moist variety a dry, hot climate is by far prefer- 
able. Whatever resort is selected the atmosphere should be free 
from dust. If the subject is anemic, and if there is complicating 
lung trouble, especially of a tuberculous character, then a mod- 
erate altitude is advantageous. If there is emphysema and the 
subject is not anemic, then the sea shore is better. The selection 
of a proper climate for chronic bronchitis is altogether an exceed- 
ingly difficult task, for it must be governed by many individual 
factors that vary in each patient. 

Hydrotherapeutic measures are of particular value in dry 
forms of chronic bronchitis and enough cannot be said in regard 
to their efficacy, especially of cold compresses applied in the form 
of crossed bandages, as fully described in the section on Acute 
Bronchitis. These compresses allay the coughing, act as a general 
sedative to the respiratory centers, liquefy the bronchial secretions 
and aid in their expectoration. 

Alkalies and alkaline and saline waters are always of value ; the 
latter both on account of their stimulating effect upon the bron- 
chial secretion and their laxative properties ; for they effectively re- 
lieve abdominal plethora and hence save the right heart much 
labor, in this way improving the circulation in the lungs. Sul- 
phur waters, too, have an important place in the treatment of 
chronic catarrhal bronchitis, for part of the sulphur is eliminated 
via the bronchi as sulphureted hydrogen, producing in its passage 
active hyperemia of the atonic mucosa, hence improving the cir- 
culation in the bronchial wall and also acting to some extent 
as a local antiseptic. 

The drug treatment of chronic bronchitis varies according 
to the character of the secretion. In the dry variety remedies 
should be administered that can aid the liquefaction of the viscid 
mucous and, at the same time, stimulate the bronchial mucosa ; to 
this group belong ammonium chloride, turpentine, balsams of 
Peru and tolu, sodium benzoate, copaiba, cubebs, santal oil, ipecac, 
tartar emetic, apomorphine; whereas in the moist variety drugs 
should be used that can diminish the excessive secretion and sim- 
ultaneously favor its expectoration, notably, belladonna, atropine, 
stramonium, hyoscyamus. All these remedies, with their dose 
and mode of administration, have been fully mentioned under 
Acute Bronchitis. 

In purulent and putrid bronchitis, disinfection and deodoriza- 
tion of the foul bronchial secretion can be accomplished either 
by the inhalation of medicated vapors or by the internal admin- 
istration of different drugs that are in part excreted via the 
bronchi. The best method of treating the bronchial mucosa by 



DISEASES OF THE BROXCHI, LUtfGS AND PLEURA 459 

inhalations is by means of a steam atomizer, using turpentine oil, Inhalations 
tincture of eucalyptus, carbolic acid (1 to 3 per cent.), thymol 
(1 to 2,000), creosote or guaiacol (1 to 2 per cent.), to medicate 
the vapors. 

Another very simple method of soothing the bronchial mucosa 
in cases of chronic bronchitis with excessive secretion is the fol- 
lowing : 

Pieces of blotting paper are spread through the room and 2 or 
3 drops of the following mixture dropped upon them several 
times a day. This frequently affords great relief and not infre- 
quently reduces the secretion. 

Menthol 

Eucalyptol aa 2.75 

01. terabinth, 

01. juniper, 

01. pin. pumil, aa 5.0 

M. Sig. 2-3 drops for inhalation. 

For internal use the balsams of Peru and tolu, guaiacol and Drugs 
thiocol, sodium benzoate, turpentine and its derivatives (see in- 
dex), fluid extract of eucalyptus, fifteen to thirty drops, or euca- 
lyptol, five to fifteen drops, repeated several times a day, or sulphur 
waters, may all be employed. 

Histosan, a proteid compound of guaiacol forming a brown Histosan 
powder of faintly aromatic taste and odor and readily soluble in 
water, is particularly valuable in chronic bronchitis, in bronchiec- 
tasis and in tuberculous cavities. It is slowly absorbed and the 
guaiacol gradually liberated, exercising its well known disinfect- 
ing and stimulating effect wherever it is needed. Histosan is best 
administered in powder form in the dose of 0.5 gm. three to four 
times a day, or dissolved in a simple syrup in the same dosage. 
It may be given for weeks and months at a time without producing 
any untoward effect, in fact it seems to exercise a gently tonic ac- 
tion on the whole system. 

In fibrinous bronchitis the most effective remedy is iodide of Fibrinous bron- 
potash, given in increasing doses, beginning with ten drops of the 
saturated solution in milk, three times a day, and gradually in- 
creasing the dose until sixty or more drops a day are being taken. 
The good effects from iodide of potash may possibly be attributed Iodide of 
to the fact that many cases of fibrinous bronchitis are due to po as 
syphilis. Inhalation of lime water through a steam atomizer is Lime water by 
the best remedy to produce loosening and expectoration of the in a atl0n 
fibrinous coagulates in the bronchi. 



460 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 



Narcotics In many cases of chronic bronchitis it becomes needful at 

some stage of the disease to administer narcotics in order to 
check the severe cough. This is necessary for the comfort of 
the patient and in order to prevent emphysema and dilatation of 
the heart, two complications that are certain to supervene unless the 
coughing is controlled. In view of the chronic character of the 
disease particular care should be exercised not to create an opium 
habit, and, for this reason, it is well to frequently change both 
the preparations of opium as well as their mode of administration, 
giving at different times opium in tincture or extract, morphine, 
codeine, heroin, dionine by mouth, hypodermically, in suppository 
or as a rectal injection. The dose should always be small and it is 

Atropine best if the patient does not know what he is getting. The addition 

of belladonna or atropine to opium preparations is usually of value. 

Strychnine Strychnine also has a place in the treatment of chronic bron- 

chitis, for it aids expectoration by its stimulating effect upon 
the bronchial musculature, the respiratory center and the heart. 
X-ray treatment in chronic bronchitis and bronchial asthma is 
occasionally of use. I have seen the sputum and the asthmatic dis- 
turbances greatly reduced under appropriate X-ray treatment. This 
seems to be particularly the case in children. 



BRONCHIECTASIS. 



Position of pa- 
tient during 
inhalations 



Danger of 
narcotics 



Bronchiectasis may well be discussed in connection with 
chronic bronchitis, for the internal treatment and the treatment 
by inhalation is essentially the same as in purulent bronchitis. 
In bronchiectasis certain mechanical features that characterize this 
disorder must be considered; thus the evacuation of the bron- 
chiectatic cavities is promoted by placing the patient every morn- 
ing in such a position that the opening into the bronchiectatic 
cavity, provided there is only one large cavity, points downward. 
In giving inhalations with the different remedies described above 
it is always well first to produce evacuation of the cavity in this 
way and then to let the patient remain in the proper position 
while inhaling; if this is done, the medicated vapor can come into 
much more intimate contact with the diseased cavity wall than if 
the latter is full of excretion. In bronchiectasis narcotics should 
be withheld, for if the sensibility of the mucosa near the orifice of 
the cavity or cavities is deadened, the normal coughing effort that 
results from contact of the putrid material with this area is 
prevented so that stagnation of the material in the bronchiectatic 
cavities is favored and the disorder is apt to be aggrevated rather 
than improved. 



DISEASES OF THE BRONCHI, LlTNGS AND PLEURA 461 

The operative treatment of bronchiectasis is still in the ex- Operative 
perimental stage. Aspiration of bronchiectatic cavities is feas- trea ment 
ible only if the exact location of the cavity can be determined by 
physical examination and if the cavity is near the surface. 
Drainage of the cavity by aspiration, and injection of antisep- 
tic fluids into the cavity, is never without danger; this procedure, 
moreover, is followed by very indifferent results, and as there is 
generally more than one bronchiectatic cavity, it is hardly prac- 
ticable. Opening the pleura for the purpose of producing col- 
lapse of bronchiectatic cavities has been extensively practised, 
but I have not been convinced in those cases in which I could 
study the patients before and after the operation, that the results 
obtained were sufficiently satisfactory to justify so precarious an 
inroad. 

BRONCHIAL ASTHMA. 



Many forms of dyspnea that are due to heart disease, ne- Cardiac, renal, 
phritis, obesity, diabetes, goutiness and lead-poisoning are com- uremic, lead, 
monly included under the name of asthma, with various prefixes 
such as cardiac asthma, renal asthma, uremic asthma, lead 
asthma, etc. These symptomatic forms of asthmatic dyspnea usu- 
ally yield to proper causal treatment directed towards the under- 
lying disorder. 

Bronchial asthma proper is a disease sui generis, of various Bronchial 
etiology. It is characterized by spasm of the bronchial muscu- asthma 
laris, generally accompanied by vaso-motor disturbance in the 
bronchial mucosa, manifesting itself by hyperemic swelling and 
narrowing of the bronchial lumen, and occasionally by the forma- 
tion of an exudate in the smaller bronchioles. 

These conditions may be produced, first, by local agencies di- Causes 
rectly affecting the upper respiratory passages and the bronchial 
mucosa, as certain forms of dust or pollen and, in predisposed 
subjects, emanations from certain animals, as well as other odors: 
second, by certain psychic factors, as a fright or an emotional 
shock, a loud noise, a flash of light and many bizarre causes, espe- 
cially in hysteric and neurasthenic subjects ; third, by reflexes start- 
ing from various organs of the body, notably, the genital sphere, 
the gastro-intestinal tract (distension of the stomach, con- 
stipation, meteorism and intestinal parasites) and, above all, the 
nasal mucosa. 

Causal treatment should take all these elements into consid- Causal treat- 
eration. It is one of the fundamental rules in the treatment of men 
bronchial asthma to carefully elicit from the patients state- 
ments in regard to those factors that seem to precipitate the at- 



462 



DISEASES OF THE BRONCHI. LUNGS AND PLEURA 



Suggestive 
treatment 



Diet 



Constipation 



Parasites 



Nasal treat- 
ment 



tacks; and however ridiculous the determining elements may seem 
to be, to take the statements of the patient very seriously into 
consideration and to proceed accordingly. The element of sug- 
gestion is very strong in many cases, particularly in hysterical 
women who have preconceived notions in regard to the elements 
that produce asthma. To ridicule their belief is bad prac- 
tice and in such cases, suggestion, even hypnotism, is useful; 
Christian Science has celebrated some of its greatest triumphs in 
the cure of such neurotic forms of bronchial asthma. In neuras- 
thenic individuals judiciously applied hydrotherapeutic meas- 
ures, as described in the Section on Gastric Neuroses, are exceed- 
ingly useful; if possible such patients should be treated for a 
time in an institution, where any ovarian or uterine trouble may 
coineidentally be corrected. 

The diet should always be carefully regulated. Overload- 
ing the stomach, particularly with starchy foods, should studiously 
be avoided. Validol, 10 to 15 drops, three times a day is one of 
the best remedies we possess to prevent the formation of gas in 
the stomach and hence it is useful in asthma associated with 
dyspeptic disturbances causing pressure upwards on the diaphragm, 
i. e., especially in the cardiac form of asthma. Constipation and 
flatulency should be combated with the means that are discussed 
under Intestinal Diseases. Intestinal parasites should be sought 
for, and if found, removed. The patients should be advised against 
going to bed during the period of active gastric digestion, in other 
words, they should never take a heavy meal at night, nor indulge 
in late suppers. 

Treatment of the nose, while occasionally followed by very 
gratifying results in bronchial asthma, is, by no means, the pana- 
cea that it is claimed to be by extremists. It is good practice in 
every case of bronchial asthma to carefully examine the nose. 
The mucosa should be cocainized and sensitive areas, so-called 
"asthma points," looked for by touching different intranasal areas 
with a probe. If marked respiratory reflexes can be elicited by 
touching such points, and especially if they are found upon a 
polypus or hypertrophied or turgescent tissues, then these over- 
growths should be removed. At all events the "asthma points" 
should be cauterized surgically. It is said that if true "asthma 
points" have been destro}^ed in this way, a febrile reaction will 
appear in the evening and persist for several days in susceptible 
individuals. If the patient will not give his consent to intra- 
nasal treatment between the attacks, then symptomatic re- 
lief can often be obtained during the paroxysm by touching the 
"asthma points" in the nose with a five to ten per cent, solution 
of cocaine hydrochloride. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 463 

There is very little to say in regard to the selection of a climate Climate 
for asthmatic subjects, for every patient is a rule unto himself. 
Some patients find relief at the sea shore, others at an alti- 
tude; some in a moist, others in a dry climate; a few people in 
the city and others in the country. It has been my experience 
that most of the cases do well after any change of climate, so 
that they should be instructed to go to one place first, and 
to seek some other locality, high or low, wet or dry, hot or cold, 
as soon as the asthmatic parox}^sms again make their appearance. 
Sufferers from hay fever asthma, of course, should select one of 
the resorts mentioned in the Section on Goryza Vaso- 
motoria. 

It is very important to attempt by all means at our disposal Interim 
to reduce the number of attacks; for in this way the affected reatment 
centers are given a rest and are enabled to regain their normal 
tone. In the interim between attacks certain remedies should 
therefore, be administered that may accomplish this purpose. The 
principal reliance can, I believe, be placed upon the iodide of 
potash, given in ten to thirty drop doses of the saturated solution 
in milk, three times a day, for three or four weeks continuously, 
then omitted for a week and then again administered for a like 
period. Such an interrupted course of iodide of potash can be Iodide of 
continued almost indefinitely, often with great relief to the patient. P otasn 
In cases of asthma associated with arterio-sclerosis the administra- 
tion of sajodin is advised. 

Next in importance to iodide of potash is arsenic, given Arsenic 
either in the form of Fowler's solution, beginning with five 
drops, three times a day, in water, and increasing the dose until 
fifteen drops, three times a day, are taken; or in the form of 
arsenious acid, sodium arseniate or sodium cacodylate. Arsenic, 
too, should be given interruptedly, the patient taking the maxi- 
mum dose for three or four weeks and then gradually reducing 
it, only to increase it again when the lowest dose is reached. 
Iodide of potash is the best remedy when there is much bron- 
chitis, emphysema or arterio-sclerosis, or if there are mani- 
festations of goutiness, whereas arsenic seems to yield better 
results in young, neurotic subjects without bronchitis or em- 
physema. 

Atropine is another useful remedy, provided the iodide of Atropine 
potash and the arsenic do not exercise the desired effect; it 
should be given in rather large doses, i. e., one-one-hundred-and- 
fiftieth to one-one-hundredth of a grain, two or three times a day 
for a considerable period of time, care being always taken that 
symptoms of atropine poisoning do not make their appearance. 
Atropine presumably acts by paralyzing the vagus terminations, 



464 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 



Treatment of 
the acute at- 
tack 



Chloroform 



Morphine 
Cocaine 



Chloral 



Bromides 



thus reducing the spasm of the bronchial musculature and sup- 
pressing the bronchial secretion. 

For the treatment of the acute attack a great many remedies 
have been recommended. It is necessary in bronchial asthma, 
owing to its manifold origin and the varying idiosyncrasies of 
many sufferers from this disease, to try a great many different 
remedies before finally one is discovered that seems to be spe- 
cifically active in the particular individual A threatening attack 
can occasionally be avoided with a mixture of digitalis and caffein. 
Every two hours a powder composed of : 

j* 

Pulv. folior digit. 0.1 

Caffein 0.2 

should be given. 

The most generally useful remedy to abort an attack is prob- 
ably chloroform, which may either be administered in small 
whiffs or given internally as chloroform water in the dose of one 
to two teaspoonfuls, or as spirits of chloroform in twenty to sixty 
drops. If the paroxysm is not promptly checked by chloroform, 
then morphine should be given hypodermically in one-eighth grain 
doses, combined with a one-two-hundredth grain of atropine and 
two to five drops of a ten per cent, solution of cocaine hydro- 
chloride; this dose to be repeated two or three times if necessary. 
As it is not practicable nor altogether safe to leave the hypodermic 
in the hands of the patient, this treatment should be reserved for 
use by the physician if he is called in early to a case of severe 
bronchial asthma. The patients may have on hand for internal 
use a solution of chloral hydrate, which is best given in combina- 
tion with large doses of bromide of potash well diluted with some 
simple syrup and water. The following prescription I have found 
useful for stopping attacks of bronchial asthma: 



Chloral hydrate, 4 gm. 

Potassium bromide, 

Simple syrup, 

Water, 

M. 

S. A dessertspoonful every hour until relieved, 



12 cc. 
32 cc. 
96 cc. 



or until four doses are taken. 
Chloralamid Chloral hydrate should, of course, never be prescribed unless 

the heart is altogether intact. A useful substitute for chloral 
hydrate in such cases is chloralamid, which may be given in doses 
of ten to thirty grains (0.65 to 2 gm.) two or three times in suc- 
cession at intervals of one hour. 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 46-5 

Very popular are asthma cigarettes made of the leaves of Asthma cig- 
stramonium, belladonna, hyoscyamus or lobelia, usually mixed 
with potassium nitrate or smoked through paper that has been 
soaked in nitrate of potash. Trousseau recommends the follow- 
ing cigarette: 

Leaves of belladonna, 0.36 

Leaves of hyoscyamus, 0.18 

Leaves of stramonium, 0.80 

Phellandrium aquat, 0.06 

The ribs are removed and the leaves cleansed, a trace of extract 
of opium added and the mixture rolled up in paper treated with 
laurel water and dried. The mixture of these leaves may also be 
cut up fine and ignited on a plate and the fumes inhaled. 

Cannabis indica is also used in the form of cigarettes and Cannabis 
very good results are claimed from its use. The following mixture indlca 
is particularly recommended by Ortner.: 

Stramonium leaves, 

Potassium nitrate, of each, 2 

Belladonna leaves, 

Cannabis leaves^ of each, 10 

The mixture may be used either in cigarettes or it may be 
mixed with nitre, ignited on a plate and the fumes inhaled. 

In order to be effective the smoke from these cigarettes must Inhalations of 
always be inhaled. It is impossible to predict in advance whether tra^e^arnmonia 
or not they will help, but it is certainly worth while to try them vapors, tobacco 
in every case. Other remedies that are used for inhalation are smoke 
nitrate of potash, which may, in a simple manner, be vaporized 
on a hot spoon. Ammonia vapors also occasionally relieve. Strong 
ammonia water is poured into a glass and the patient after plug- 
ging his nostrils with cotton inhales the whiffs of ammonia that 
are carried to his mouth by fanning across the top of the vessel. 
It is finally worthy of mention that some patients obtain marked 
relief from smoking tobacco. 

It is always good practice during the attack to develop steam Steam 
in the room. Sometimes relief is obtained if the patients repeat- 
edly dip their hands or feet, or both, into hot water. Whether 
this is a reflex vaso-motor effect or pure suggestion is hard to de- 
termine; yet as the measure can do no harm, often does good, and 
is very simple, it should be advised. 

One of the most important elements in the treatment of asthma Psychotherapy 
is carefully guided psychotherapy combined with systematic phys- 



466 



DISEASES OE THE BRONCHI, LUNGS AND PLEURA 



Breathing 
exercises 



ical training in regard to breathing. There is in all cases of 
asthma a disproportion between the objective and the subjective air 
hunger. 

Breathing exercises may be carried out according to the fol- 
lowing plan: 

In the first place the forcible expiratory movements should be 
suppressed by teaching the patient to avoid all unnecessary muscu- 
lar activity in producing expiration and allowing the elasticity of 
the thorax to do most of the work. At the same time the patient 
should be taught to prolong the inspiratory movements and to 
make inspiration deeper, in order to approximate by volition, nor- 
mal breathing. The former task is the more difficult of the two 
and it requires a great deal of training and much exercise of 
will power to suppress the stormy respiratory efforts that these 
patients undertake. If the patient can be taught when the patho- 
logic type of breathing is really beginning, and if at the very onset 
he conscientiously attempts to regulate his breathing and keep it 
nearly to the normal rhythm, then a great deal is gained. A very 
good method to help the patients to regulate respiration is to in- 
struct them to count out loud, stretching the vowels as much as 
possible. 



Involvement 
of the right 
heart 



Hydrotherapy 

Lukewarm 
baths 



CAPILLARY BRONCHITIS— BRONCHO-PNEUMONIA. 

Catarrh of the smaller bronchioles (bronchitis profunda, bron- 
chiolitis capillaris), especially in children and old people, fre- 
quently extends to the infundibula and ultimately involves the 
lobules of the lungs. From a clinical point of view, therefore, it 
is practical to consider capillary bronchitis and broncho-pneumonia 
together. 

Owing to t^ie occlusion of numerous air channels and the nar- 
rowing of the bronchial lumen in either disease, the aeration of 
the lungs becomes deficient so that an excessive amount of labor 
is thrown both upon the right heart and upon the muscles of 
respiration. In most cases fever sets in that in its turn exercises a 
deleterious effect upon the heart muscle. Most cases, therefore, 
as will readily be understood, die not from the bronchial and pul- 
monary inflammation directly, but rather from embarrassment 
and failure of the right heart. One of the main objects of treat- 
ment, consequently, should be to support the heart, relieve the 
respiratory muscles of their excessive labor and reduce the tem- 
perature. 

Here lukewarm baths (90° to 96° F.) gradually reduced to 
75° or 60°, or followed by cold sponging, are the sovereign rem- 
edy. The explanation of their action is the following: By im- 
mersion in water that is somewhat below the normal body tern- 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 467 

perature a preliminary contraction of the cutaneous vessels is 
produced, especially in febrile cases; this is followed by a reactive 
dilatation of these vessels which can be markedly enforced by 
rubbing the patient while he is in the bath. The primary shock 
and the sudden contraction of the skin vessels causes reflex stim- 
ulation of the heart and of the respiratory centers as manifested by 
a rise of the blood pressure and a few deep inspirations. The 
passive hyperemia of the skin which follows, in its turn de- 
pletes the bronchial mucosa, relieves the heart, reduces the blood 
pressure and quiets respiration. The effects of the primary 
shock are very transitory, whereas the reaction persists for a long- 
time. A second reaction can be secured if the patient upon leav- 
ing the bath is rapidly sponged with cold water of room tem- 
perature and is at once put to bed between warmed linen sheets 
and given the benefit of an energetic dry surface massage. The 
duration of the bath should not exceed ten to fifteen minutes and 
two or three such baths may be given during the day. This bath 
treatment is particularly useful in cases of capillary bronchitis 
affecting strong individuals without pulmonary involvement and 
without high fever. In all cases it is good practice to give a 
teaspoonful or two of brandy before the bath. If myocardial or 
arterio-sclerotic changes are present such cool baths should, of 
course, never be given. 

Instead of cool baths the cold pack may be applied as fol- Cold pack 
lows: A linen sheet is wrung out of water of from 50° to 65° 
F., and the patient quickly wrapped up in the sheet and covered 
with a woolen blanket. Here, too, there is a preliminary shock, 
promptly followed by the desired reaction. It is best to cover 
only portions of the patient's body at a time, applying the sheet 
once to the thorax, then to the abdomen and then to the legs. 
In very nervous subjects and in cases suffering from much dyspnea, 
I have made it a rule always to leave the arms free when admin- 
istering a wet pack, for wrapping the sheet around the arms 
causes a sense of restraint and oppression that excites and wor- 
ries the patients and reacts unfavorably upon the heart's action 
and the blood pressure — conditions which should be avoided. The 
cold packs should be repeated at short intervals until the tempera- 
ture is lowered several degrees. As a rule, after the first pack the 
temperature at first falls quickly, but rises again as quickly, i. e., 
within a few minutes, so that it usually requires three or four 
applications of the wet sheet to keep the temperature permanently 
down. 

In some forms of capillary bronchitis there is no fever, the Hot bath 
patients even develop sub-normal temperatures with cyanosis and 
cold hands and feet; here cold hydrotherapeutic measures are al- 



468 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 



Hot pack 



Moistening 
the air 



Rest in bed 



Change of 
position 



Diet 



together out of place and the hot pack or the hot bath should be 
given instead. Contra indications to the use of hot hydro- 
therapeutic measures are myocardial changes and arterio-sclerosis. 
In giving the hot pack the sheet is wrung out of water of 100° 
to 105° F., and the patient speedily wrapped into it and covered 
as above; or the patient may be placed into a bath of 100° F. for 
ten or fifteen minutes. In either case an ice bag or cold cloths 
should be applied to the head. As soon as the hot cloth is removed 
or the patient leaves the hot water, the skin should be ener- 
getically rubbed with a warm rough towel and the pa- 
tient placed to bed and covered with linen or cotton bed- 
clothing. 

The good effects of the hot bath must be attributed to the 
passive hyperemia of the skin that sets in promptly, for the dilata- 
tion of the superficial capillaries that is produced is practically 
synonymous with bleeding the patient into his own vessels; the 
fall in the blood pressure that results herefrom greatly relieves 
the heart without depressing it. Here, too, as in the case of cool 
bathing, the first contact with the hot water stimulates deep res- 
pirations and aids expectoration. The prolonged exposure to heat, 
besides, exercises a very desirable sedative influence on the nervous 
system, most patients promptly falling asleep after such 
bath. The temperature occasionally rises slightly while the 
patient is immersed in the hot water, but in febrile cases it 
generally drops 2 or 3 degrees as soon as the patient is 
back in bed. 

The air in the room should always be kept moist. This is 
best done by hanging sheets wrung out of hot water in the 
room, or by developing steam from a kettle or pan. In children 
the bronchitis tent described elsewhere may be used and steam de- 
veloped underneath it. 

Cases that set in with high fever, and all cases of capillary 
bronchitis developing in children and old people, should be kept 
in bed, preferably in a semi-recumbent position; the patients 
should be ordered to frequently change their position so as to 
prevent hypostatic congestion of the lungs. Little children with 
capillary bronchitis should be frequently lifted out of bed and 
carried about. 

The diet should be very strengthening but not bulky. No 
articles of food should be given that can dilate the stomach or 
produce gaseous distension of the stomach or bowels, as, other- 
wise, the heart's action may be mechanically interfered with and 
full excursions of the diaphragm downward prevented, so that 
coughing and expectoration would be rendered difficult. The 
diet should, therefore, be largely albuminous, consisting of scraped 



DISEASES OF THE BRONCHI, LUNGS AND PLEURA 469 

meats, broth, milk, eggs, with a little fresh fruit and fresh vege- 
tables and a minimum of starchy foods and fats. Little food or 
drink should be taken at one time, the patient preferably eating 
small meals at frequent intervals. A little alcohol in the form of 
dilute claret, Ehine wine or whisky throughout the disease can do 
no harm; the alcohol acting beneficially both on account of its 
food value and on account of its general stimulating and sup- 
porting effect upon the heart. If symptoms of heart 
weakness appear, alcohol is by far the best stimulant in this 
disease. 

The bowels should be kept open throughout the course of Regulation of 

the disease. Constipation and intestinal flatulence or meteorism * he J. owel 
r function 

are to be carefully avoided in order not to interfere with the 
movements of the diaphragm. In the beginning free catharsis 
should be promoted by a tablespoonful of castor oil, or by calomel 
best given in one-tenth grain doses repeated ten times and fol- 
lowed by a tablespoonful of magnesium sulphate in water. Later 
a mild saline laxative or wine of cascara may be given in doses 
sufficiently large to produce one or two free evacuations of the 
bowels every day. 

The medicamentous treatment of the bronchitis per se does Medicamentous 
not differ very materially from that advised in other forms of treatment 
acute bronchitis. If the disease sets in suddenly with high fever, 
drop doses of the tincture of aconite every two or three hours Aconite 
should be given. Narcotics should be used very sparingly, as it Narcotics 
is self-evidently always dangerous to suppress the cough and 
stop the expectoration. If the cough is very distressing, if it is 
wearing the patient out, preventing sleep or straining the heart, 
as manifested by an irregular heart action after each coughing 
effort, then a five-grain dose of Dover's powder, or one-eighth 
grain of morphine with one-two-hundredth grain of atro- 
pine, or a one-fourth grain of codeine, may be administered 
several times a day. Stimulating expectorants as strychnine, Stimulating 
senega or ammonium chloride, and small doses of the emetic expectorants 
expectorants, ipecac, tartar emetic, apomorphine, may be Emetic expec- 
given with the reservations and precautions outlined in the 
Chapter on Valvular Lesions and the Section on Acute Bron- 
chitis. 

As soon as alarming signs of heart weakness appear, heart Heart tonics 
tonics must be given. I have made it a practice to give very 
small quantities of digitalis or strophanthus, i. e., two or three 
drops of the tincture several times a day from the very onset of 
the disease. In this way the heart's action is rendered more reg- 
ular, while, at the same time, no over-stimulation is produced. I 
have never seen any ill-effects from this practice. If small doses 



470 DISEASES OF THE BRONCHI, LUNGS AND PLEURA 

are given larger doses always remain available for emergencies. 
If signs of heart failure appear suddenly (and if the case is care- 
fully watched from the beginning and treated with small doses 
of heart tonics this failure is not apt to appear unexpectedly), 
camphor, ether, ammonia must be given hypodermically and the 

Analeptics patient sponged or douched with very cold and very hot 

water alternately. On rare occasions it may become neces- 

Oxygen sary to resort to inhalations of oxygen, combined with the 

use of strychnia in one-twentieth to one-fortieth grain doses, 
given hypodermically in order to overcome cyanosis, excessive 
dyspnea and lividity. 

The treatment of the convalescent stage is the same as in any 
other form of bronchitis. 



CHAPTER IX. 

DISEASES OF THE LUNGS AND PLEURA.* 

PULMONARY EMPHYSEMA. 

On account of the mechanical and destructive character of the Limitations of 
lesion in pulmonary emphysema a cure of this disorder is mani- rea men 
festly out of the question. We are dealing with a rarefaction of 
the intralobular septa either throughout the lung or in certain 
circumscribed regions (as in compensatory or traumatic emphy- 
sema) with atrophy of the alveolar walls, obliteration of capil- 
laries and loss of elastic tissue and, in many cases, anatomic 
rigidity of the chest wall with ossification of costal cartilages. 

When one considers further that in many cases of emphysema, Hereditary 
especially when occurring in young people (with or without the element 
co-operation of factors like over-exertion and violent respiratory 
efforts incident to various occupations), a distinctly hereditary ele- 
ment, manifesting itself by abnormally high intra-pulmonic blood 
pressure and congenital weakness of the alveolar walls must be 
included in the question, then it becomes clear that even prophy- 
lactic treatment directed towards checking the progress of emphy- 
sematous changes when they first make their appearance is gen- 
erally a futile task. 

For all these reasons the treatment of emphysema is of neces- Treatment 
sity largely symptomatic. Our efforts must be directed chiefly to- lar gely symp- 
wards counteracting the bronchitis that complicates and aggra- 
vates most cases of the disease; then towards preventing or 
correcting the dilatation and hypertrophy, especially of the right 
heart, that generally precede or follow emphysema ; and towards re- 
lieving the signs of venous stasis about various organs that develop 
consecutively to the cardiac insufficiency. Finally the asthmatic 
seizures and the attacks of dyspnea that render the existence 
of advanced cases of emphysema so hard to bear must be ener- 
getically treated and if possible relieved. 

In undertaking to treat the bronchial catarrh in any case of The complicat- 
emphysema of the lungs it is very important, as a preliminary m S brcmchial 

*Pulmonary Tuberculosis and Pneumonia see Chapter I "Infectious 
Diseases." 



472 



DISEASES OF THE LUNGS AND PLEURA 



Expectorants 



Cardiac tonics 



Significance of 
bloody sputum 



Catarrhal 
asthma 



step, to determine whether the bronchial catarrh preceded the em- 
physema or whether it developed consecutively to emphysematous 
rigidity of the lung. This point can usually be determined with 
some degree of accuracy from the history. 

If the bronchitis preceded the emphysema then it is presumably 
of the simple catarrhal variety, and here the various cough reme- 
dies, sedatives, expectorants, etc., that have been described in full 
in the Section on Chronic Bronchitis have their field of useful- 
ness. 

If the bronchitis developed after the emphysema, then it is 
generally due to venous hyperemia of the bronchial mucosa pro- 
duced by the impeded pulmonary circulation and the weak action 
of the right heart that so commonly supervenes in pulmonary 
emphysema. If a careful examination of the heart reveals dila- 
tation of the right half and marked accentuation of the second 
pulmonary sound and if, at the same time, evidence of venous stasis, 
due to cardiac insufficiency, is discovered in other regions of the 
body, then venous stasis can be charged with producing the bron- 
chial catarrh, and the treatment should be largely cardio-tonic, 
as described in the section on Valvular Diseases in the stage of 
failing compensation. 

Unfortunately the exact determination of the heart bounda- 
ries is frequently a very difficult matter in emphysema because 
the superficial heart dullness is commonly obliterated in emphy- 
sema of the anterior margins of the lungs, and because deep per- 
cussion does not yield very positive information in advanced de- 
grees of emphysema. The presence of a little blood in the spu- 
tum may aid in the differential diagnosis between hyperemic 
catarrh, of the bronchi, due to venous stasis, and simple bronchitis, 
slight degrees of hemoptysis speaking for hyperemia of the 
bronchi. 

A therapeutic test, finally, with heart tonics may aid in the 
decision; for venous stasis in the bronchi, i. e., hyperemic catarrh, 
yields readily to the judicious use of these tonics, where- 
as catarrhal bronchitis is in no way influenced by cardio-tonic 
medication. 

There is still another variety of bronchial catarrh in em- 
physema that assumes the characteristics of catarrhal asthma. 
The dyspnea is paroxysmal and spasmodic and the sputum in 
many cases contains eosinophile cells. Here, too, the catarrhal 
asthma may have preceded the emphysema, or it may have fol- 
lowed it, the former being the more common event. The treat- 
ment of this variety of bronchial catarrh must be carried out as 
described in full in the Section on Bronchial Asthma. 



DISEASES OF THE LUNGS AND PLEURA 473 

It will usually be found that if the bronchitis, scil., the 
cough, expectoration and the asthmatic paroxysms, are held in 
check the patients notwithstanding their emphysema will feel 
relatively comfortable, in fact, rarely suffer from their emphysema 
per se unless the latter is so far advanced as to materially re- 
duce the breathing surface of the lung, and to cause marked in- 
sufficiency of the right heart with all that that entails. Hence, 
it is a matter of greatest importance to determine the exact cause 
of the bronchial trouble and to attack it energetically. 

The dyspnea that emphysematous patients suffer from calls for Dyspnea 
the same careful analysis as the bronchial catarrh. It may be 
due either to the emphysema itself, i. e., it may result from the 
reduction of the breathing surface of the lung, or it may be 
paroxysmal in character, i. e., an asthmatic dyspnea, or it may be 
due to cardiac insufficiency. In the latter case appropriate car- 
dio-tonic treatment is usually effective; in asthmatic dyspnea 
the treatment is the same as given in the Section on Bronchial 
Asthma. 

In view of the chronic character of emphysema the choice of Climate and 
a resort or a climate and of the proper altitude is exceedingly im- resorts 
portant. Here, as in the selection of all the other remedial meas- 
ures that are to be employed, the exact causes that determine the 
complications, chiefly the bronchitis and the dyspnea, must be 
considered and advice rendered accordingly. 

Thus in the selection of an altitude everything will depend Altitude 
upon the condition of the heart, the severity of the bronchial 
catarrh and the degree of emphysematous dilatation of the 
lung. 

If the emphysema predominates and the bronchial catarrh Moderate aJ- 
is relatively slight and the cardiac insufficiency not far advanced, titudes 
then a moderately high altitude should be selected, for these pa- 
tients complain chiefly of difficulty in getting rid of the 
air, that is, of expiratory dyspnea; so that the low barometric 
pressure at an altitude -and the rarefied air render expiration 
easier and hence help the patient. Incidentally slight degrees 
of bronchial catarrh are not unfavorably influenced by an alti- 
tude. 

If, on the other hand, the catarrhal condition of the bronchi Southern low 
predominates so that there is abundant irritating secretion and climates 
much cough with resulting strain upon the heart, then these pa- 
tients should be advised against seeking high altitudes and should 
live in a Southern climate at a low barometric pressure with the 
minimum of temperature changes, a maximum of clear, sunshiny 
days and little humidity in the air. The latter requirements can 
frequently only be met in semi-tropical arid regions ; here however 



474 



DISEASES OF THE LUNGS AND PLEURA 



Sea shore and 
sea voyages 

Pneumatic 
chamber 



Laxative 
waters 



Diet 



Little albumen 



No large meal 



Reduction of 
obesity 



the dust and alkali in the air usually constitute a serious irritant 
to the bronchial mucosa and produce violent coughing efforts — 
therefore the climatic advantages are often neutralized in this 
way, so that emphysematous patients should be sent by preference to 
moist, warm, rather than to dry, warm climates. For such cases 
the seashore in Southern regions, or an ocean voyage through 
Southern seas, is of signal benefit. 

Patients who cannot seek a proper climate occasionally derive 
benefit from the use of pneumatic chambers at home and in re- 
sorts located not too far from home. A great many different 
kinds of apparatus have been constructed by means of which the 
patient breathes under pressure; all of them improving the 
bronchial catarrh of emphysema provided it is due to hyperemia of 
the bronchial mucosa. Symptomatically, too, breathing compressed 
air helps many cases of emphysema; the exact scientific explana- 
tion of this clinical fact is still forthcoming. 

In choosing a resort for an emphysematous case the character 
of the waters may be advantageously considered in addition to 
the altitude and climate and the facilities for breathing com- 
pressed air. Kesorts furnishing laxative waters should be given 
the preference for by the judicious use of saline laxatives ab- 
dominal plethora is corrected and hence the right heart relieved 
of much labor and breathing thus facilitated. On the same 
principle catharsis by saline laxatives should be promoted at 
home. 

The diet should be selected with the object in view chiefly 
of preventing abdominal plethora and over-loading or distension 
of the stomach. Consequently the diet should not contain too 
much albuminous pabulum, for the latter produces engorgement 
of the mesenteric veins during digestion, i. e., abdominal plethora 
more than other food. The use of aerated beverages and of 
fermenting foods chiefly of the starchy variety, should be inter- 
dicted. If necessary anti-fermentative remedies (see Meteorism) , 
may be given from time to time to prevent flatulency and distention 
of the stomach and bowel. In cases with a tendency to dyspnea 
large meals should never be allowed; the patient should be in- 
structed to eat small meals at frequent intervals. All these dietetic 
rules are intended to prevent pressure upon the diaphragm from 
below by a distended stomach or bloated bowel and hence inter- 
ference with free respiratory excursions. 

If the patient with emphysema is obese, then a reduction cure 
is an exceedingly useful element in the treatment ; for the presence 
of large quantities of intra-abdominal fat interferes with the res- 
piratory movements of the diaphragm downward and hence in- 
creases the dyspnea, an effect that is enforced by the weight of large 



DISEASES OF THE LUNGS AND PLEURA 475 

fat masses "upon the thorax. Obese patients, moreover, as a rule 
suffer from abdominal plethora, constipation, flatulency, all factors 
that should be counteracted in emphysematous dyspnea. Finally, 
the heart, as is well known, is particularly over-strained in ad- 
vanced degrees of obesity. This is due in part to the presence 
of fat masses around the organ and infiltration of the heart muscle 
by fat, or to fatty degeneration of the heart muscle; in part to 
the great resistance offered to the flow of blood by the fine network 
of capillaries that forms in new adipose tissue ; and to many other 
causes that have been discussed in full in the Section on Obesity. 
Some of the most gratifying results are obtained precisely in 
obese emphysema cases suffering from much dypsnea, bronchitis 
and symptoms of stasis in various organs as soon as the bulk of 
the patient is reduced by a carefully carried out cure. For the 
choice of method and the technique of the latter I refer to the 
Section on Obesity. 

Occasionally a patient with advanced emphysema suddenly Venesection 
develops quite alarming degrees of dyspnea and cyanosis that en- 
danger his life. In such cases without regard to what the exact 
pathogenesis of these phenomena may be in the individual case 
(and time will rarely be given to make a careful analysis of all 
the contributing factors) bleeding is the sovereign remedy. From Oxygen in- 
two to three hundred cc. of blood should be removed at once from 
the median basilic vein, as described elsewhere. At the same time 
inhalations of oxygen may be given ; two or three gallons of oxygen 
being administered every two or three hours. If the excitement 
is great and the patient very restless, then an hypodermic injection Morphine 
of an eighth of a grain of morphine with a two-hundredth of 
atropine frequently furnishes prompt relief. While these measures 
are being carried out the heart should be supported by the hypo- 
dermic administration of analeptics, camphor, ether, ammonia, Analepetics 
strychnia, given as described in detail in the Section on Valvular 
Diseases of the Heart in the stage of failing compensation. 



PULMONARY EDEMA. 

There is an inflammatory pulmonary edema due to local pro- Collateral pul- 
cesses and occurring in the neighborhood of acutely inflamed 
areas, infarcts, tumors, etc., of the lungs, mediastinum and pleu- 
ral cavities. This so-called collateral pulmonary edema is due 
either to local injury produced in the vessel walls of a given vicinity 
by bacterial toxins, or it may be due to plugging of blood-chal- 
nels and lymph spaces, or to mechanical compression of the latter 
in circumscribed areas of the lung. This local pressure or plugging, 



476 



DISEASES OF THE LUNGS AND PLEURA 



Angioneurotic 
edema 



Toxic edema 

Edema due to 
stasis 



Pulmonary 
edema usually 
due to several 
factors 



Condition of 
the heart im- 
portant 



Cardiac tonics 



with or without degeneration of the vessel walls by toxins per- 
mits diapedesis of serum and probably also of corpuscles into the 
air cells and the alveolar tissues of certain circumscribed regions 
of the lung and, in this way, produces localized pulmonary edema. 

This variety is rarely amenable to treatment other than that 
directed towards the underlying cause. In fact, the edematous 
area is often so small as to cause little discomfort and produce 
few symptoms. If large areas of the lungs become edematous 
from this source, then the symptomatic treatment is the same as 
that of any other form of acute pulmonary edema. 

Edema due to paralysis of the musculature of the pulmonary 
arteries may be a part phenomenon of hysteria (angio-neurotic 
edema) or it may occur in the course of chronic intoxications as, 
e. g., in uremia, acute alcohol poisoning, lead-poisoning, iodide- 
poisoning, etc. 

The most common form of pulmonary edema, however, is that 
produced by stasis in the pulmonary veins. This is an edema of 
the lungs that accompanies general disorders involving the com- 
petency of the heart, hence it often constitutes a terminal phenome- 
non in a variety of infectious and chronic cachectic disorders; it 
also occurs in valvular diseases of the heart and in cardiac disorders 
of manifold origin, fatty heart and myocarditis. 

In most cases of pulmonary edema several of the above factors 
are operative; thus, for instance, in uremic edema occurring 
in cardio-renal disease there is at the same time chronic intoxication 
from renal insufficiency, and a weakened heart and weakened blood 
vessels. In pulmonary edema occurring in infectious diseases, as 
typhoid, measles, influenza, pneumonia, etc., there is a general 
bacterial toxemia and often, at the same time, myocardial degen- 
eration as a result of the infection. In pulmonary edema occur- 
ring in the course of anemia and cachectic states there is usually 
injury to the structure of the blood vessel walls from malnutrition 
and, at the same time, a heart with a weakened myocardium and 
self-evidently with a tendency to dilatation and insufficiency. 

It will be seen, therefore, that in almost all cases of chronic 
pulmonary edema the condition of the heart must, above all things, 
be seriously taken into consideration, hence the treatment differs 
somewhat according to the condition of the heart. 

One can for therapeutic purposes distinguish between cases 
of chronic pulmonary edema in which the heart's action is good and 
the myocardium apparently intact, and cases in which the heart's 
action is weak and in which evidences of myocarditis, dilatation, 
fatty degeneration, etc., are apparent. 

The latter variety of cases is by far the most common of the 
two. Here the judicious use of cardiac tonics and of all the other 



DISEASES OF THE LUNGS AND PLEURA 477 

hygienic^ dietetic and hydrotherapeutic measures that have been 

described in full in the Section on Valvular Diseases of the Heart 

in the state of broken compensation must be employed. Here, too, Catharsis 

active catharsis and the stimulation of diuresis and diaphoresis, * U1 ? S1S . 

r Diaphoresis 

with all the precautions and reservations that have been discussed 

at length in the above section, have a useful field of application. 

Dry cupping over the chest is a useful adjuvant to the treatment, Cupping 

especially in those peculiar cases of cardio-renal edema of the lung 

in which the edematous effusion seems to occupy circumscribed 

regions of the lung only. 

In all cases of chronic pulmonary edema particular care should Avoidance of 

also be exercised to avoid the administration of certain drugs that jpdids and 

° bromids 

can produce hyperemia and congestion of the bronchi, notably 

iodides and bromides. This warning is appropriate because in many 

cases of chronic pulmonary edema insomnia, due to the difficulty 

of breathing and possibly to circulatory disturbances of the brain 

that result from the cardiac insufficiency, is a very distressing 

symptom. Here the temptation is always given to administer 

bromides. On the other hand many cases of cardio-renal disease 

develop on the basis of a syphilis, so that a course of antiluetic 

medication with large doses of iodides might seem indicated. 

Acute edema of the lungs developing as an exacerbation of Acute edema 
chronic edema or occurring suddenly and independently, imma- 
terial what its origin, calls for rapid interference, for this disorder 
always constitutes an emergency that threatens the life of the pa- 
tient. 

The best remedy in many cases is atropine or its congeners, Atropine 
hyoscine, scopolamine. These remedies should be given hypoder- Hyoscine 
mically in large doses, that is, in doses of one-sixtieth to one- copo amine 
thirtieth of a grain (1 to 2 mg.) repeated two or three times, or 
oftener, at intervals of one hour. To give smaller doses is, in my 
experience, a waste of time. The after-effects of the large doses 
of atropine or hyoscine are disagreeable, but one is dealing with a 
life and death question in which unpleasant sensations affecting 
the patient should not be considered. The action of atropine and 
hyoscine is to stimulate both the respiratory centers and, at the 
same time, the vaso-constrictors ; in this way, in all probability, 
counteracting the mechanical dilatation of the vessel walls and ren- 
dering them less permeable to blood serum. In acute edema occur- 
ring in the course of chronic cachectic diseases and in disorders 
accompanied by malnutrition and degeneration of blood vessel 
walls no ready response to vaso-constrictor influences will be ob- 
tained ; but cases advanced to this point are almost invariably fatal 
and as no harm can be done by giving atropine in large doses a 



478 



DISEASES OF THE LUNGS AND PLEURA 



Ergot 



trial, one need not hesitate to begin the emergency treatment, even 
in such cases, with large doses of atropine or hyoscine. 

Second in importance to atropine is ergot. This drug also is 
given on account of its power to cause constriction of blood vessels 
in certain areas of the body. Ergot does not produce general vaso- 
constriction, otherwise it would raise the general blood pressure 
much more than it does. It causes constriction merely of the blood 
vessels in certain areas of the body ; we know positively that it exer- 
cises this effect about the female adnexa, whether it exercises the 
same effect upon the pulmonary blood vessels we do not know 
absolutely, but some experimental evidence seems to indicate that 
Action of ergot it does. Empirically and clinically we know, at all events, that it 
raises the blood pressure in the pulmonary circulation and hence 
we are justified in concluding that it also exercises a local vaso- 
constrictor effect ; for this reason the remedy is useful in pulmonary 
edema, and for the same reason it is so dangerous in hemoptysis; 
for if there is rupture or erosion of blood vessels within the pul- 
monary area the beneficial effects that might accrue from the 
vaso-constriction are more than neutralized by the rise in blood 
pressure that is at the same time produced. 

If given in pulmonary edema it should be used either in the 
form of the injectia ergota hypodermica in the dose of three to 
twenty drops, or by mouth as the solid extract of ergot in doses 
of three to sixteen grains (0.2 to 1 gm.). It can, to advantage, be 
combined with atropine and the following combination I have found 
useful and safe: 



Mode of ad- 
ministration 



Cacodylate of 
soda 



3 

Atropine, 1-50 gr. (0.0013 gm.) 

Extract of ergot, 10 gr. (0.6 gm.) 

M. Sig. One capsule every hour until relieved 
or until four are taken. 

Still another remedy that may be used as an emergency measure 
in pulmonary edema is cacodylate of soda. This preparation of 
arsenic should be given in large doses in order to be effective. It 
exercises a most remarkable influence upon exudates and edematous 
effusions without, to my knowledge, possessing any disagreeable 
after-effects. It is perfectly safe to give sodium cacodylate hypo- 
dermically in one grain doses, in watery solution, every three or 
four hours, for four or five doses. A convenient way to administer 
the remedy is to have a solution of fifteen grains of cacodylate of 
soda to the ounce of water made and to inject a Pravaz needle full 
subcutaneously or intramuscularly every three or four hours. When 
one considers that one grain of cacodylate of soda contains as much 
arsenic approximately as three-fifths of a grain of arsenious acid, 



DISEASES OE THE LUNGS AND PLEURA 479 

the absence of symptoms of arsenic poisoning after the adminis- 
tration of this drug is very remarkable. 

If there is much cyanosis in acute edema with other evidence of Analeptics 
embarrassment of the right heart, then active cardio-tonic medi- 
cation becomes necessary. Here the character of the pulse, the 
size of the heart, the strength of the apex beat and its reaction must 
all determine the dosage of the various analeptics and cardio-tonics 
that are to be administered. The same principles should govern 
us here as in the treatment of cardiac stasis due to decompensated 
valvular lesions. Ether, ammonia, camphor, camphor in ether, 
camphor in oil, champagne and, in less acute cases, digitalis, 
strophanthus, caffein, all have their application. 

Venesection may be practised in extreme cases and very marked Venesection 
relief is frequently obtained from the withdrawal of two or three 
hundred cc. of blood. It is always safe and good treatment, if none 
of the above emergency medicines are immediately available, or if 
they do not act very promptly, to bleed the patient as a prelim- Leeches to 
inary measure. In the same sense the application of leeches to the anus 
anus, i. e., bleeding from the hemorrhoidal veins occasionally helps. 

In advanced cases of cardia incompetency with venous stasis Paracentesis of 
in the portal area and abdominal ascites, paracentesis of the abdo- D o t a i ? m ? n in 
men and withdrawal of some of the ascitic fluid frequently exercises with pulmonary 
a very beneficial effect upon the pulmonary edema. This effect edema 
must be attributed to the relief of pressure produced within the 
abdomen which enables the veins of the portal area to expand more 
readily and consequently to harbor more blood within their lumen. 
Abdominal puncture in these cases is, therefore, in a sense, bleeding 
the patient into his own blood vessels. 



PULMONARY INFARCT, ABSCESS AND GANGRENE. 

In view of the mechanical character of the lesion in pulmonary 
infarct the treatment is largely symptomatic. 

Prophylaxis is in a sense possible; for given on the one hand Prophylaxis 
a phlebitic process about one of the extremities, the brain sinus, 
uterus, the hemorrhoidal veins, about recent fractures, or on the 
other hand, a weak right heart with endocardial disease, or both, 
then the possibility of embolus formation and pulmonary infarc- 
tion must always be remembered. Hence the existence of any 
of the above named conditions should put us on the alert for pul- 
monary infarct and the attempt should be made to prevent its de- 
velopment. 

The principles that should govern this prophylactic treatment Principles of 
are the following: We know from experience that there is less P ro P n y laxi s 



480 



DISEASES OF THE LUNGS AND PLEURA 



Rest and im- 
mobilization 
in acute 
phlebitis 



Danger of mas- 
sage and in- 
unctions in 
phlebitis 



Treatment of 
sudden infarc- 
tion 

Artificial res- 
piration 

Oxygen 



probability of embolus formation in the marantic variety of phle- 
bitis thrombi that develop as a late phenomenon in chronic cachec- 
tic disease, cancer, severe anemias, phthisis, etc., than in thrombosis 
due to acute phlebitic processes. This is owing to the fact that 
marantic thrombi develop slowly and are consequently better or- 
ganized, i. e., more solid and more adherent to the vessel walls 
than thrombi that develop rapidly as the result of acute phlebitis; 
and also to the fact that sufferers from marantic thrombosis are 
usually very weak and of their own inclination remain quiet, while 
patients with acute phlebitis are strong, apt to be restless and to 
move about a good deal, hence favoring the breaking off of emboli 
from the thrombus. 

In acute phlebitic disease consequently every effort should be 
made to favor slow development of the thrombus and to keep the 
patient quiet, in this way rendering the breaking off of fragments 
of the thrombus and hence embolization and infarction in remote 
regions of the body less probable. 

Every patient with phlebitis should therefore be put at rest 
in a recumbent posture and should be warned against performing 
any sudden movement. If the phlebitic process is going on in 
some extremity of the body then the latter should be immobil- 
ized with loose bandages or splints and kept perfectly quiet in a 
horizontal position. Massage of the affected limb should not be 
given nor inunctions, that are so popular in phlebitis, be admin- 
istered. Eest of the body and of the affected extremity should be 
maintained until all the sequelae of blood vessel occlusion have 
disappeared, that is, until the extremity has regained its natural 
red color and temperature and size.. As long as the limb is swol- 
len, pale, cool and edematous there is danger of embolization. 
In phlebitic processes, involving the pelvic or the hemorrhoidal 
vessels, straining at stool, violent coughing efforts and hiccough 
should be avoided as much as possible. 

If in spite of these precautions, that cannot unfortunately be 
carried out successfully in every case, the patient suddenly experi- 
ences a pain in the chest, begins to cough violently, becomes 
dyspneic, possibly spits some blood and faints, then infarction of 
the pulmonary vessels with extravasation of blood into the pulmon- 
ary air cells and the interstitial tissues of some region of the lung 
may be suspected. 

The treatment of this syndrome is the following : If the patient 
is in syncope, as a result of the infarction, he should be placed in 
a horizontal position. If there is much dyspnea artificial respira- 
tion should be practised and oxygen inhalations given. At the same 
time hot compresses should be applied over the chest. If the heart 
is weak> the pulse feeble and rapid, then analeptics should at once 



DISEASES OF THE LUNGS AND PLEURA 481 

be administered beginning with a hypodermic of thirty minims of Hot compresses 
ether and following with an injection of camphor in ether or cam- Anal eptics 
phor in oil. 

As soon as the patient revives from his faint an injection of Morphine 
a quarter-grain of morphine with two-hundredth of a grain of 
atropine is given in order to allay restlessness and excitement. If, 
shortly after the infarction, evidence of pulmonary edema begins 
to appear, then two or three hundred cubic centimeters of blood 
should be withdrawn by venesection from the median cephalic vein 
as described previously. If the hemoptysis is very abundant then Venesection 
this complication should be treated as described in the Section on 
Hemoptysis. The bleeding from the lung is rarely very profuse 
or persistent in pulmonary infarct and it is well to remember that 
infarction of the lungs may occur without any hemoptysis. 

If the infarction in any particular cases is attributable more 

to thrombosis of branches of the pulmonary artery from the right 

auricle than from embolization originating in some phlebitic process 

in a remote portion of the body, and if there is tangible evidence 

of cardiac dilatation and insufficiency, then cardiac tonics, digitalis Cardiac tonics 

at their head should be administered, an ice bag should be ap- Ice bag 

plied to the precordium and venesection performed. If, however, 

the hemorrhage from the lungs is very severe, then venesection is 

contra-indicatd. 

Pulmonary Abscess and Gangrene. 

In connection with the treatment of pulmonarv infarct a few Pulmonary 

abscess 
words may be said in regard to the treatment of pulmonary abscess, 

for this lesion not infrequently develops as the result of pulmonary 
infarct due to occlusion of a pulmonary vessel by a septic embolus. 
The symptomatic treatment of pulmonary abscess dependent upon 
this cause in the beginning corresponds to that of any other form 
of pulmonary infarct. 

In fully developed pulmonary abscess due to septic infarct 
from septic phlebitis or endocarditis, or to any other cause, as the 
aspiration of a septic foreign body, purulent breaking down of a 
pneumonic or tuberculous focus, etc., or in abscess occurring as a 
part phenomenon of a general pyemia, internal treatment is prac- 
tically of no avail and the case becomes a surgical one, i. e., tfte 
indications are created for opening the abscess by pneumotomy and 
establishing drainage. If there is only a single abscess cavity, and Pneumotomy 
if it can be definitely located, the injection of antiseptic fluids, as 
carbolic acid, iodoform emulsion, menthol, may be tried, but this antiseptic 
treatment is very uncertain, never without danger and essentially fluids 
surgical in character, so that the injection treatment of pulmonary 
infarct need not be discussed in this volume. If the abscess cavity 
ruptures into a bronchus the treatment becomes synonymous with 



482 



DISEASES OF THE LUNGS AND PLEURA 



Rupture of the 
abscess 



Gangrene of 
the lung 



Injection of 

antiseptic 

fluids 

Fetor of the 
breath 



Internal reme- 

edies 

Turpentine 

Myrtol 

Eucalyptol 



that described in the Section on Bronchiectasis, if it ruptures into 
the pleural cavity an empyema is created which should be treated 
according to the rules laid down in the Section on Pleuritis. 

Gangrene of the lungs, finally, may occasionally follow em- 
bolism of the pulmonary artery and infarction of certain areas of 
the lungs. This development, however, is relatively rare and, as 
a rule, gangrene follows pneumonia, bronchiectasis or invasion of 
the lung by a foreign body either via a bronchus or the pleura. 
Here, too, internal treatment is unsatisfactory. Surgery has a 
definite field in the treatment of this disease, as in the treatment 
of abscess of the lung, and here, too, if it is possible to circum- 
scribe the gangrenous area, the injection of certain antiseptic solu- 
tions (by a surgeon!) has a place. 

The internist is often called upon to treat special symptoms. 
The horrible fetor of the breath is an especially disagreeable ac- 
companiment of this disorder. Inhalations of turpentine, laven- 
der oil and tincture of eucalyptus are especially useful, employed 
either singly or combined. From five to ten drops of any of these 
preparations should be poured on hot water and the vapors in- 
haled through a paper cornucopia as described on page 459, or a 
few drops of the various oils may be inhaled through a steam 
atomizer. A two per cent, solution of carbolic acid inhaled in the 
same way is also frequently efficacious in correcting the bad 
breath. 

A valuable prescription to cause disappearance of the dis- 
agreeable fetid odor in pulmonary gangrene is a two per cent, solu- 
tion of chloral nitrite in water, used as a mouth wash, and also to 
be added to the sputum after it is expectorated. 

For internal use the rectified oils of turpentine, myrtol and 
eucalyptol are especially valuable. If given in sufficiently large 
doses the expired air soon acquires an odor of turpentine, myrtol 
or eucalyptus, showing that a portion of these remedies is excreted 
through the lungs. Whether they act merely as deodorizers or also 
as disinfectants it is difficult to say. Their administration never 
does harm and often seems to aid materially in restoring healthier 
conditions. Rectified turpentine oil, myrtol and eucalyptol are 
best given in capsules in two minim doses every two or three hours 
until the breath smells of the drugs. It is well, in order to protect 
the stomach, to give some fat after these oils have been taken; or 
the patient should be ordered to drink a glass of milk with cream 
or to eat a piece of bread and butter after each capsule. A very 
simple plan, too, is to administer oil of turpentine directly on 
bread and butter. 

That the general health and the nutrition of a patient suffer- 
ing from circumscribed pulmonary gangrene should be raised to 



DISEASES OP THE LUXGS AND PLEURA 483 

the highest possible standard by plenty of fresh air and a nutritions 
diet, suitable to the functional powers of the patient's digestive 
apparatus, is self-evident. 

HEMOPTYSIS. 

Hemoptysis properly speaking means hemorrhage from any Definition 
portion of the respiratory tract, i. e., the pharynx, trachea, bronchi, 
or the lungs. The hemorrhage may either be due to rupture or 
erosion of one of the large blood vessels lining the respiratory 
tract, or to rupture of an artery adjacent to the air passages into 
the lumen of the latter, or it may be due to capillary oozing, that 
is, diapedesis of blood through the weakened walls of congested 
veins and. capillaries in the respiratory mucosa. 

Hemorrhage from the lungs may occasionally be a protective Hemoptysis 
process and. one that does not call for any interference. This ap- protective 7 
plies particularly to three varieties of hemoptysis, viz., first hemor- process 
rhage occurring before and during the period of menstruation; 
second, hemorrhage occurring in certain heart lesions, notably mitral 
and tricuspid insufficiency; third hemorrhage occurring in appar- 
ently healthy subjects, usually in adolescents. 

The treatment of hemoptysis occurring before and during the Vicarious 
menstrual period, i. e., vicarious menstruation through the respira- e p ysis 
tory passages, is the same as that described, under vicarious epis- 
taxis. An effort should be made to bring about bleeding from the 
uterus by hot vaginal douches, hot mustard foot baths, catharsis 
and the use of emmenagogue remedies, chief among then pil. aloes 
et ferri, five grains (0.3 gm.) two or three times a day, or cimici- 
fuga, which should be given in doses of five drops of the fresh 
tincture every four or five hours for two or three days preceding 
the expected menstruation. 

Hemoptysis due to pulmonary stasis from valvular disease Hemoptysis in 
may usually be considered in the light of a "safety-valve" action g^ u 
released by Nature to relieve engorgement of the right heart 
and embarrassment of the pulmonary circulation. It has its 
analogue in the hemorrhoidal bleeding so frequently seen in portal 
stasis due to obstructive processes (cirrhosis or stasis within the 
liver from heart disease). As a rule this form of hemoptysis calls 
for no intervention. In frequently occurring pulmonary or bron- 
chial hemorrhages, however, due to heart disease with the loss of 
large quantities of blood, cardiac tonics, as described in the Section Cardiac tonics 
on Decompensated Heart Lesions are the chief remedies to be em- 
ployed ; and the results from this therapy are always satisfactory. 

As a prophylactic measure against such hemorrhages it may Prophylaxis 
become necessary to adminisier some opiate in order to reduce the °P iate * 



484 



DISEASES OF THE LUNGS AND PLEURA 



Expectorants 
Ipecac 



Hemoptysis of 
adolescence 



Rest and 
avoidance of 
heart tonics 



Hemoptysis 
from ulceration 
in the upper air 
passages 



Topical treat- 
ment 



straining effort incident to violent or persistent coughing. In 
other cases if the hemorrhage is so severe as to fill up large areas 
of the bronchial tree so that there is danger of suffocation, or if 
the patient after the hemorrhage experiences great difficulty in 
expelling the blood clots, so that there is danger of secondary 
infection (pus germs and other bacteria finding a suitable nidus 
for their development in the stagnating and disintegrating blood), 
then it may become necessary, as an extreme measure, to choose 
the smaller of two evils and to administer expectorants. The best 
remedy in these cases is ipecac root, given either in three or four 
large doses of fifteen grains (1 gm.), each, every hour, until vom- 
iting occurs (Trousseau), or in small doses of one and one-half 
grains (0.1 gm.) every ten minutes to the point of nausea (Jac- 
coud). It will rarely become necessary, however, to adopt this 
somewhat precarious procedure and it must always be considered 
as a violent emergency measure adopted as a last resort to save 
a suffocating patient. 

Closely related to hemoptysis from valvular disease seems the 
hemoptysis occurring in healthy adolescents. The patients rarely 
feel any serious discomfort from the hemorrhages, which are 
generally slight. The explanation of these hemorrhages is difficult 
to give. It is probable that in rapidly-growing adolescents there 
develops a relative inadequacy of the heart's capacity due to the 
fact that the heart cannot keep up with the increasing labor that 
is imposed upon it when the body grows rapidly. As a result tem- 
porary insufficiency with dilatation of the ventricles, chiefly of 
the right heart, relative muscular insufficiency about the mitral 
and tricuspid valves occurs with venous engorgement in the pul- 
monary circulation and hemorrhage from the lungs. The theory 
is borne out by the frequent discovery in such cases of systolic 
murmurs at the apex and over the tricuspid area. The best treat- 
ment for this form of hemoptysis is rest and careful administra- 
tion of heart stimulants and heart tonics. The young people should 
be warned against excessive exercise and should be instructed to 
lead a quiet life, physically, mentally and emotionally. As a rule 
the heart soon adjusts itself to the increased demands upon its 
powers and the hemoptysis disappears never to return again. 

Hemorrhages from ulcers in the larynx and trachea are 
amenable to the same treatment as hemorrhages in any other ex- 
posed region of the body, provided the bleeding spot can be seen 
through the laryngoscope. Here the same rules apply as in the 
treatment of epistaxis due to similar causes. The hemorrhages 
can often be arrested by the application of a silver nitrate stick 
or of alum powder or, best of all, of the actual cautery, care being 
taken, if the latter is applied, to withdraw the point of the cautery 



DISEASES OF THE LUNGS AND PLEURA 485 

while it is still hot, as otherwise the eschar may be torn off when 
the instrument is removed. 

Hemorrhages from aneurism of the aorta are in most cases Hemoptysis 
very profuse and rapidly fatal so that no opportunity is given for £j£sar£m l ° 
any treatment. If the patient does not succumb at once to the 
loss of blood or to suffocation from flooding of the bronchial tree 
with blood, then the treatment becomes the same as that in any 
other form of pulmonary hemorrhage from an eroded blood vessel 
(see below). 

Hemoptysis not due to vicarious hemorrhage nor to heart Emergency 
lesions and not occurring in an adolescent, under the conditions hemoptysis 
outlined above, but resulting from erosion of an artery (the pro- 
totype of such a hemorrhage being the hemoptysis of pulmonary 
tuberculosis) should be treated as follows: Upon the occurrence 
of the hemorrhage the patient should immediately be put to bed 
and kept in a sitting or semi-recumbent position, as it is easier to * osltlon 
expectorate the blood when in this position than when lying down. 
If the loss of blood is so severe that the patient faints, then no 
effort should be made at first to revive him by the use of stimulants, 
as clotting is favored when the patient is unconscious. If the loss 
of blood is. not so severe as to produce fainting, then above all things Fainting 
the patient's excitement should be allayed, if necessary by the 
hypodermic injection of a quarter of a grain of morphine with one- Morphine 
two-hundredth grain of atropine. In some cases it is best to refrain 
from the use of hypodermic medication, especially if the patient is 
afraid of the needle; in others it is well to insert a hypodermic 
needle if for no other reason than to give the patient the assurance 
that energetic measures are being instituted to save his life. The 
physician in such an emergency must be guided by the tempera- 
ment of the individual patient. 

If a physical examination, rapidly made, or if previous knowl- ag 

edge of the patient's lungs enables the physician to suspect from 
what part of the lungs the hemorrhage has occurred, and especially 
if there is pain in a circumscribed area of the chest, then an ice- 
bag should be applied over this point. If the bleeding spot cannot 
be definitely localized in a tuberculous case, then it is always safe 
to apply small ice-bags over the apical region. At all events an 
ice-bag should be placed over the heart in order to quiet its reac- 
tion and reduce its frequency. A very good plan is to apply the 
ice-bag intermittently over the suspected lung area and over the 
precordium, leaving it in each place for an hour. 

Eest in bed, morphine and the application of ice to the region g 0( ji um 
of the heart are intended, above all things, to reduce the rapidity of nitrite 
the heart's action and to lower the blood pressure. The latter pur- 
pose can also be fulfilled by the use of aconite or of sodium nitrite. 



486 



DISEASES OF THE LUNGS AND PLEURA 



Stimulants 



Hemostan 



Ligation of 
extremities 



Opiates 



Administration 



the former to be given in drop doses until the character of the 
pulse reveals that the blood pressure has been reduced; the latter 
in doses of one to two grains (0.05 to 0.1 gm.) repeated every three 
or four hours. Great care should be exercised not to produce too 
great depression and if the hemorrhage is severe and the pulse low 
and feeble when the patient is first seen, it is evident that remedies 
like aconite and nitrites are contra-indicated. In the latter cases 
heart stimulants like strychnine, brandy, camphor, coffee, ether may 
be required to save the patient's life. 

In all forms of hemorrhages the following remedy, known 
under the term hemostan, in the close of one to three tablets, three 
times a day, is useful: 

Extr. fl. hydrastid. Canad. 

Extr. gossyp. spiss. 

Extr. hamamelid sicci aa 3.0 

Quinine mur. 1.0 

Pulv. rad. hydrast. 9.0 

M. Ft. Tablettae. 

S. 1 to 3 tablets three times a day. 
Of other general measures that should be employed in pul- 
monary hemorrhage, ligation of the extremities with a bandage or 
a piece of rubber tubing is a useful procedure. The bandages or 
rubber ligatures should be applied so tightly that the venous 
back flow is impeded, while the progress of the blood into the limbs 
through the afferent arteries is not interfered with. The liga- 
tures should remain in place from a quarter of an hour to 
one hour. This plan of treatment is intended to rvjduce the volume 
of blood flowing through the bleeding area and hence to favor co- 
agulation. 

Of remedies that should be given in hemoptysis opiates oc- 
cupy the first place. Opium or morphine may be given either 
by mouth or hypodermically (see above). If the insertion of 
the hypodermic needle does not excite the patient too much, the 
latter plan is by all means preferable. Occasionally the admin- 
istration of opium or morphine by suppository or clysma becomes 
necessary (Dose and administration, see index). Opiates do not 
act as hemostatics but merely stop the cough and hence allay 
straining efforts; they also counteract restlessness and excitement 
and hence prevent high arterial tension from this source. Theo- 
retically opiates are contra-indicated because they produce con- 
gestion in the peripheral vessels. Their exact mode of action upon 
the pulmonary vessels, however, is not altogether understood, and 
as we know empirically that they are highly efficacious in hemop- 
tysis their use can be warmly recommended. 



DISEASES OE THE LUNGS AND PLEURA 487 

Of other hemostatic remedies ergot should, above all things, be Dangers of 
eschewed for reasons that have been explained in full in the Sec- 
tions on Epistaxis and Pulmonary Infarct. Hemorrhage in the 
minds of many practitioners, spells ergot as the remedy and how- 
ever correct ergot treatment may be in hemorrhage from the uter- 
ine cavity so incorrect it is in hemorrhages from most other por- 
tions of the body. 

Tannic acid has been used extensively. It is questionable Tannic acid 
whether it is very trustworthy as a hemostatic in hemoptysis. The 
best form in which to administer tannic acid, and the one in 
which the drug does the least injury to the stomach, is as the 
fluid extract of hamamelis, which should be given in thirty minim Hamamelis 
(2 cc.) doses, in water, every two or three hours. 

Lead acetate, which for a long time was very popular, is men- Lead acetate 
tioned to be condemned. Lead acetate acts very well locally, but 
if given in doses large enough to reach the bleeding spot in a 
concentration that could promote arrest of hemorrhage, general 
lead-poisoning, nephritis or severe gastro-intestinal disturbances 
would assuredly develop. If given in smaller doses it would be in- 
effective as an hemostatic. 

Oil of turpentine given in five drop doses in milk or on bread Turpentine 
and butter, every two or three hours, is a valuable remedy especial- 
ly in slow, persistent bleeding from smaller vessels, and I have seen 
several cases of hemoptysis yield to this treatment when all other 
remedies seemed to have failed. 

The most reliable hemostatic we possess, however, is hydrastis Hydrastis 
canadensis. It may be given as the fluid extract in doses of fifteen 
to sixty minims (1 to 4 cc), in milk, every hour for four or five 
doses; as hydrastinine hypodermically in doses of one-half to two Hydrastinine 
grains (0.03 to 0.1 gm.) ; as cotarnine (stypticine) in doses of Cotarnine 
one-third to one-half grain (0.02 to 0.03 gm.), in watery solution, 
by mouth or hypodermically every hour for four or five doses or 
until the desired hemostatic effect is produced. 

Gelatin has been used extensively in hemoptysis. In order to Gelatin 
be efficacious it must be given in large doses. A very good method 
of administering it by mouth is to prepare a solution consist- 
ing of: 

Common salt, 1 

Gelatin, 10 

Water, 200 

M. Sig. Of this mixture about one-third is given 

in one dose and two or three tablespoonfuls 

every hour thereafter. 



488 



DISEASES OF THE LUNGS AND PLEURA 



After treat- 
ment 



Diet 



Causal treat- 
ment of slow 
hemoptysis 



Sometimes the administration of gelatin hypodermically aids 
in arresting hemoptysis, but this plan can usually only be carried 
out in a hospital where a carefully sterilized gelatin solution is 
ready for immediate use. It is always a dangerous procedure to 
administer gelatin hypodermically or intravenously in private 
practice, because gelatin is made from the hoofs of animals and, 
unless very carefully sterilized by discontinued sterilization on 
several successive days, may contain live spores of tetanus. Leav- 
ing this danger aside, the injection of gelatin at best is not 
an indifferent procedure, for the patients often react with 
slight fever and much local pain. For the technique of ad- 
ministering gelatin subcutaneously, see also the Section on 
Aneurism. 

After the hemoptysis has been stopped the patient should 
remain in bed for some time. It is a good rule to keep the pa- 
tient perfectly quiet until the last traces of blood have disap- 
peared from the sputum. During this time he should be forbid- 
den to speak loudly, to call or to otherwise strain the voice and in- 
dulge in violent respiratory efforts. 

In order to prevent straining at stool it is always best to 
lock the bowels for several days by the administration of opiates. 
Later evacuation of the bowel contents should be made easy for 
several weeks after the hemorrhage by the administration of ap- 
propriate laxatives (see index) or the use of enemas. 

In the beginning the patient should be kept on a liquid diet con- 
sisting, during the first days only, of small doses of ice-cold 
milk given frequently, later gruels, a little fresh fruit and vege- 
tables, soft boiled eggs and, last of all, meat and meat prod- 
ucts may be permitted. Tea, coffee, alcohol, very hot foods and car- 
bonated beverages should be denied as long as there is any oozing 
of blood. 

The causal treatment, finally, of slow hemoptysis occurring in 
the course of leukemia, the hemorrhagic diathesis and severe pri- 
mary anemia is synonymous with the treatment of the underlying 
disorder. The symptomatic treatment of this form of hemorrhage 
does not differ from that of any other variety of hemoptysis of a 
slow character. Hemoptysis in pneumonia rarely calls for special 
treatment. 

The treatment of the secondary anemia following severe hem- 
orrhages or the continued loss of small quantities of blood through 
slow oozing from the respiratory tract has been fully described in 
the Section on Secondary Anemia. 



DISEASES OF THE LUNGS AND PLEURA 489 

PLEURITIS. 



From a therapeutic standpoint the etiological and anatomic 
classification of the different forms of pleuritis is of very little 
value. It is clinically often a very difficult matter to differen- 
tiate between fibrinous, sero-fibrinous and fibrous pleurisy, for 
the reason that small amounts of fluid in so-called dry pleurisy 
frequently escape detection, and because many cases of fibrinous 
or fibrous pleurisy very gradually develop into exudative forms 
with liquid in the pleural cavity. 

The opinion is prevalent that most cases of simple primary 
pleurisy are tuberculous in character. Hence the casual treat- 
ment would be the same as that described in the Section on Pul- 
monary Tuberculosis. 

There remain a small minority of cases of pleurisy that are 
not tuberculous and that follow simple exposure to cold. Whether 
or not this exposure acts by preparing a suitable nidus in the pleura 
for the invasion of micro-organisms, or whether germ infection 
has nothing to do with this variety, one cannot always determine; 
at all events the existence of an idiopathic pleuritis, following ex- 
posure to cold, must be postulated that, for lack of a better name, 
may be called rheumatic. 

This rheumatic form of pleurisy in contradistinction to all 
other forms is amenable to causal treatment, for, here, the salicylate 
preparations exercise a very apparent effect upon the course of 
the disease. In order to be useful salicylates must be given in 
large doses, either as sodium salicylate in fifteen to twenty grain 
(1 to 1.3 gm.) doses, four or five times a day, or as salol (phenyl 
salicylate) in the same doses, or, best of all, as aspirin (acetyl 
salicylate) in doses of thirty to forty-five grains (2 to 3 
gm.) two or three times a day. Antipyrin, too, in doses of five 
to ten grains (0.3 to 0.6 gm.) given three or four times a day 
in combination with one of the above salicylates is of value in 
some cases. 

This salicylate treatment with or without antipyrin is with- 
out effect in the tuberculous variety of pleurisy and in those 
forms that are due to the invasion of the pleural cavity by other 
bacteria. If there is evidence, therefore, of a tuberculous focus 
or of bacterial infection anywhere in the body; if the onset of the 
disorder is not sudden and does not develop manifestly from ex- 
posure to cold and chilling of the body surfaces, then the above 
salicylate treatment is not to be employed. For no good can be 
accomplished by it and there is always danger of deranging the 
stomach and bowel and irritating the kidneys when large doses 
of salicylic acid or its derivatives are administered. 



Most cases of 
simple pleurisy 
tuberculous 



Pleurisy follow- 
ing exposure to 
cold 

("Rheumatic 
pleurisy") 



Salicylates in 
rheumatic . . 
pleurisy 

Sodium sali- 
cylate 
Salol 
Aspirin 
Antipyrin 



Inefficacy of 
salicylates in 
tuberculous 
form 



490 



DISEASE'S OF THE LUNGS AJSTD PLEURA 



Treatment of 
acute pleurisy 



Position in bed 



Diaphoresis 
Dover's powder 
Whisky 
Hot air 



Electric light 
bath 



Hot bathing in 
dry pleurisy 



A case of acute pleurisy upon the onset of the first sypmtoms 
of pain in the chest, dyspnea, cough and fever should be put to 
bed and should be kept there until the temperature is normal. 
The position that the patient occupies in bed should be largely 
left to himself, and it is wrong in these cases to be arbitrary in 
regard to this matter on theoretical grounds. Some patients 
prefer to lie on the unaffected side, especially in the beginning of 
the disorder, because it hurts them very much to lie on the sick 
side. Other patients prefer to rest on the affected side in order 
to aid in immobilizing the chest where it hurts and instinctive- 
ly, possibly, by the pressure to reduce the local hyperemia. When 
much exudate has been poured out the patients almost invariably 
prefer to lie on the affected side, in fact most of them cannot 
lie comfortably on the unaffected side. This is due to the fact, 
self-evident, that they wish to give the healthy side of the chest 
the greatest freedom for expiratory excursions. 

In the beginning of an attack of pleurisy diaphoretic treat- 
ment is often useful. Medicinally this is best brought about by 
the administration of a ten grain Dover's powder given with a 
glass of hot lemonade to which a tablespoonful of whisky or 
brandy is added, preferably taken in the evening before going to 
sleep. In addition the patient may to advantage undergo a sweat 
in the hot air bath. The latter can be arranged as described in 
the Section on Cardiac Dropsy, by suspending blankets over the 
patient supported by hoops or a wooden framework and conducting 
heat from an alcohol lamp, placed on the floor, through a funnel 
and rubber tube arrangement underneath the blanket tent. Great 
care should, of course, be exercised that the end of the tube from 
which the hot air rises does not come into immediate contact with 
the patient's person, as otherwise very disagreeable burns can be 
produced. If electricity is available in the house, then a chain 
of incandescent lamps can be suspended underneath the blanket 
tent, or inside of a wooden box constructed for the purpose, and 
degrees of temperature sufficiently high to cause profuse sweat- 
ing generated in this way. The patient should remain in this hot 
atmosphere for an hour or two with cold cloths or an ice bag 
applied to the head. When the blanket tent is removed the patient's 
skin should be thoroughly dried with a rough towel and rubbed 
down with alcohol. 

In cases of pleuritis without exudate immersion in a hot bath 
is also a very useful procedure to bring about sweating. The pa- 
tient should be placed in a bath of from 98° to 100° F'heit and 
instructed to lie perfectly still in the water for fifteen minutes. 
Here, too, an ice bag or cold cloths should be applied to the head 
in order to prevent reactive hyperemia of the brain. While in 



DISEASES OF THE LUNGS AND PLEURA 491 

the bath the patient should be given plenty of water to drink. 
After leaving the bath the skin should be rubbed down thorough- 
ly with a rough towel and alcohol. 

While these general measures are being employed every effort 
should be put forward to counteract the hyperemia in the pleura, 
and incidentally to stop the pain and the cough. This can be 
done by local applications to the chest, by strapping the affected 
side with adhesive plaster and by the administration of mor- 
phine. 

Counter-irritation by the application of five or ten leeches to Counter-irrita- 
the skin over the pleuritic area is a very useful means of pro- * lon 
cedure, especially in the beginning of the trouble. The technique Wet CUDD j ng . 
of leeching has been described in full. Wet cups with or with- 
out scarification are also of some use as a local counter-irritant. In 
early stages of pleurisy dry cups should, however, never be used 
as otherwise ecchymosis of the underlying pleural membranes may 
be produced. 

One of the best and simplest counter-irritants is a large mus- Mustard 
tard plaster. This is prepared by mixing equal parts of mustard and P laster 
wheat flour and moistening this mixture with warm dilute vine- 
gar. This mass is smeared in a thin layer on a piece of linen 
lying on a thick sheet of paper and another piece of linen is 
placed over the mixture. This plaster is laid upon the chest 
with the paper to the outside and left in place until burning sets 
in, it is then removed and the skin treated with olive oil. 

Heat and cold per se act as effective counter-irritants to the Cold and heat 
chest wall. Here the sensations of the patient must be our guide, 
some feeling very much more relieved by the application of cold 
to the pleuritic area, others by the application of heat. The ice 
bag or a Leiter coil may serve the former purpose; poultices made Ice bag 
of oatmeal, flaxseed or bread and medicated with a few drops of Leiter coil 
the tincture of opium or belladonna the latter. Poultices 

The best effects are produced, however, by cool Priesnitz com- Priesnitz 
presses (see index) applied by wringing a linen cloth out of water 
of room temperature, applying it to the affected area and cov- 
ering it with a piece of flannel ; this compress is left in place 
for three or four hours and then renewed. At the end of this 
time the linen will be found to be dry and the underlying skin 
hyperemic, showing that a counter-irritant effect has been pro- 
duced. 

Chloroform may also be used as a counter-irritant, but, on Chloroform 
account of its blistering properties it is not so pleasant to bear. 
If it is used at all, pure chloroform should be rubbed into the 
skin over the affected area and the treated region covered with 



492 



DISEASES OF THE LUNGS AND PLEURA 



Iodine 



Anodyne 
ointments 



Cantharidal 
plaster 



Strapping the 
chest 



Technique 



Morphine for 
cough and pain 



Pain referred 
to remote 
regions 



oiled silk. Iodine, too, may be used as a counter-irritant but is 
not so effective as the other measures enumerated above. 

If the pain is very severe certain anodyne ointments may be 
used. Two very useful ones are : 



9 



Menthol, 
Cocaine muriate, 
Vaseline, 



And 



I* 



Chloral hydrate, 

Camphor, 

Vaseline, 



2.5 
1.0 

60.0 



2.00 

0.5 

50.00 



In those cases in which the pleuritic process remains strictly 
circumscribed for several days, and very early in exudative forms 
of pleuritis, a cantharidal plaster applied once is of value. A 
piece of the plaster about six inches square is applied to the 
painful area and left in place six hours. The large blister that 
forms should be opened at once under careful aseptic precautions 
and with sterile instruments. 

If counter-irritation fails to bring about relief, then it may 
become necessary to strap the chest with broad strips of adhesive 
plaster. The immobilization of the diseased side of the thorax 
that is brought about in this way is always grateful to the patient 
and often very effective in hastening recovery. To strap the chest 
one should proceed as follows: The patient is instructed to sit 
on the edge of the bed or to stand up with the affected side away 
from the physician. The middle of a strip of adhesive plaster 
is pressed against the axillary region of the patient while the 
two ends are held by the physician. The patient now presses 
against the strip or is pulled away from the operator by an as- 
sistant and with the chest in an expiratory position the ends of 
the strip are tightly fastened to the middle of the chest and 
back. Two or three strips of this kind may be applied according 
to the extent of the pleuritic affection. 

If the pain is excruciating and the cough very severe, then 
hypodermic injections of morphine, one-eighth to one-fourth 
grain, repeated if necessary, may have to be given. On account 
of the suggestive effect it is usually best to inject the 
morphine directly into the intercostal muscles over the painful 
area. 

In pleurisy, on account of the peculiar distribution and 
termination of the intercostal nerves that are being irritated, it 



DISEASES OF THE LUNGS AND PLEURA 493 

is well to remember that the pain is frequently referred to re- 
mote regions of the body, so that a patient with a mild 
pleurisy may complain of severe distress in the lumbar region or 
in the anterior abdominal region of either side, thus simulating 
gall-bladder or appendiceal affections, lumbago, renal colic, etc. 
These pains, too, can frequently be stopped by local counter-irri- 
tation over the affected area in the pleura and by the hypodermic 
use of morphine. 

If active treatment instituted early fails to prevent the forma- Diuresis and 
tion of an exudate, or if the patient is seen for the first time catharsis in 
with fluid in the pleural cavity, then in addition to the measures pleurisy 
spoken of above diuresis and catharsis must be stimulated in the 
hope that depletion may aid in the absorption of the exudative 
product. 

The stimulation of diuresis (see also Section on Cardiac Caffein 
Edema) is of questionable value unless it is combined with the Theobromin 
drink restriction to be discussed presently. Of the diuretics that 
can be employed the caffein group occupies the first place. Caffein Diuretin 
citrate in doses of two to eight grains (0.1 to 0.5 gin.), or theo- Digitalis 
bromin in eight grain doses (0.5 gm.), or, best of all, diuretin, s< l ullls 
the double salt of sodium theobromin and sodium salicylate, in 
doses of eight to ten grains (0.5 to 0.6 gm.) may all be given 
several times a day. Digitalis and squills, the former as the ex- 
tract of digitalis in doses of one-sixth to one-third gr. (0.01 to 0.02 
gm.), the latter in thirty to sixty minim (2 to 4 cc.) doses of 
the syrup of squills, are also useful and can profitably be given 
combined with one of the above mentioned caffein preparations. 
The acetates of sodium and potassium in doses of 15 to 60 grains Sodium and 
(1 to 4 gm.), taken with plenty of hot water several times a day acetate 11 " 
are also very useful as diuretics. 

For the purpose of promoting catharsis salines given in con- Epsom, Glau- 
centrated form, preferably in the morning on an empty stomach s || r t ' s oc e e 
are by all means the best remedy. A tablespoonful or two of 
Epsom salts, Glauber salts or Eochelle salts by drawing water 
into the intestine by osmosis (see Constipation) produce some 
concentration of the blood and the latter in its turn becoming 
more concentrated than the pleuritic exudate abstracts water from 
the pleural cavity. A useful preparation to produce watery stools Compound in- 
is the compound infusion of senna, containing as a very use- fusion of senna 
ful ingredient magnesium sulphate. The dose of the remedy is 
two fluid ounces once or twice a day. It is rarely necessary to 
stimulate very active catharsis by the use of jalap or elaterium. 
If these remedies are to be used, two to five grains (0.1 to 0.3 
gm.) of the resin of jalap, or a quarter to one grain (0.016 to Jalap 
0.06 gm.) of the trituration of elaterin, may be given. Elaterium 



494 



DISEASES OF THE LUNGS AND PLEURA 



Drink re- 
striction 



Autosero- 
therapy 



Fibrolysin 



Thoracentesis 



When to as- 
pirate 



Indications for 
thoracentesis 



Thoracentesis 
in hemorrhagic 
exudates 



The good effects derived from diuresis and catharsis upon the 
absorption of the pleuritic exudate are often enforced by the 
use of a dry diet, i. e., a diet containing the minimum of liquids 
(see Cardiac Dropsy). Here the desire for water may be some- 
what mitigated by allowing patients to eat ice pills, to chew gum 
or to suck peppermint or menthol lozenges. 

Autoserotherapy is often a valuable means, both in tubercu- 
lous and non-tuberculous serofibrinous pleurisy, to produce a dis- 
appearance of the exudate. 1 cc. of the exudate is aspirated into 
an hypodermic needle and the pleuritic fluid obtained in this way 
immediately injected under the skin. This procedure should be 
carried out every other day and one will be surprised to see how 
often the exudate disappears. 

Injections of fibrolysin, one ampule (Merck), two to three 
times a week may be tried in pleuritic adhesions. No harm can 
accrue from this procedure and occasionally good results are ob- 
tained. 

As a last resort in the treatment of pleurisy with effusion 
aspiration of the fluid by thoracentesis must be considered. It is 
often a difficult matter to decide just when to tap the chest. 
Axiomatically one may say that it is always better to aspirate too 
soon than too late, for if the pleuritic exudate is allowed to remain 
in the pleura too long the lung is very apt to lose its elasticity and 
its power of expansion, and interstitial pneumonia, carnification of 
the lung and bronchiectasy are quite liable to develop. Moreover, 
if the exudate is very large, so that it compresses the lymph 
stomata in the pleura, absorption of the fluid is automatically pre- 
vented. 

The chief indications for thoracentesis are persistence of the 
exudate at the expiration of three or four weeks and despite the 
employment of all the measures spoken of above; then, bilateral 
exudative pleurisy developing rapidly and producing severe ortho- 
pnea; and, again, severe subjective symptoms due to dislocation 
of the heart with twisting or compression of the large vessels at 
the base of the heart, with pulmonary edema, cerebral anemia, 
peripheral cyanosis, stasis in the abdominal viscera and other re- 
mote symptoms that can be directly attributed to the presence of 
fluid in the pleural cavity. Finally, tapping of the chest may be- 
come necessary as a palliative measure in carcinomatous and sar- 
comatous processes involving the pleura. In the latter class of 
cases the fluid is usually hemorrhagic in character and almost in- 
variably reappears after thoracentesis. Here, therefore, one should 
be conservative in tapping the pleura, for the repeated hemorrhages 
into the pleural cavity are without doubt weakening to the patient, 



DISEASES OF THE LUNGS AND PLEURA 495 

so that the removal of the fluid, in this class of cases, should be 
undertaken only when the subjective symptoms become distressing 
or directly endanger life. 

The dangers incident to the operation of thoracentesis are 
often grossly exaggerated. It is true that accidents may happen Dangers of 
after withdrawal of fluid from the chest under rigid asepsis, or 
if the fluid is too rapidly removed, especially if due care is not 
exercised in working, notably embolization of cerebral or pul- 
monary arteries, syncope from cerebral anemia, paralysis of the 
heart, pneumothorax, empyema, expectoration of albuminous spu- 
tum, etc. If the aspiration is carried out carefully and if emer- 
gency remedies are kept at hand to prevent all possible complica- 
tions about the heart and circulation, then thoracentesis is fraught 
with very slight danger. One should have ready, therefore, for Preparation for 
such emergencies, analeptics, i. e., a hypodermic syringe filled with oracen esis 
a ten per cent, solution of camphor in ether and a hypodermic of 
one-thirtieth grain of strychnine sulphate, also some smelling salts 
and a small glass of brandy or whisky. 

Before performing thoracentesis it is always best to give the Morphine be- 
patient a quarter of a grain of morphine, hypodermically, to quiet c °ntesi s™' 
him and to subdue his fear and excitement somewhat, so that he 
may co-operate with the operator to the best of his ability and also 
to prevent, as far as that is possible, the cough which so frequently 
follows withdrawal of pleuritic exudate. 

The little field of operation should be rendered thoroughly Technique 
aseptic by scrubbing with soap and water and a 1 : 2, 000 bichlo- 
ride solution, alcohol and ether. A preliminary puncture should 
always be made with a hypodermic needle in order to ascertain 
with certainty that fluid is present about the spot where it is Asepsis 
intended to insert the trocar, and also in order to insure the 
absence of a pleuritic adhesion at the point within the area of 
dullness that has been selected for the puncture. 

In selecting the place of puncture two regions are usually The place of 
considered. Either a point in the fifth, sixth or seventh inter- 
space in the anterior axillary line, or a point posteriorly in the In the anterior 
seventh or eighth interspace near the outer angle of the scapula. axl ary 
The former location is the better of the two, for while the bulk 
of the fluid usually accumulates posteriorly after the patient has 
been lying down for days, so that the insertion of the needle at 
the angle of the scapula is most apt to strike the fluid, still the At the outer 
posterior intercostal spaces are narrower and the muscles of the scapula 
back are thicker than in the axillary line, so that the needle must 
be pushed in deeper and must overcome more resistance. The 
fluid, moreover, in the posterior part of the chest is apt to contain 
more abundant flakes of fibrin than in front, owing to the fact 



496 



DISEASES OE THE LUNGS AND PLEURA 



Danger of 
wounding the 
diaphragm 



Position of 
the patient 



Local anes- 
thesia 



Aspiration of 
the fluid 



Dressing the 
puncture 



Quantity of 
fluid to be 
withdrawn 



that the latter sink by gravity; consequently posteriorly there is 
always more risk of occlusion of the needle. 

The puncture should always be made as low down on the thorax 
as possible, care being taken, of course, not to wound the dia- 
phragm. The exact location of the diaphragm is, therefore, best 
determined first on the healthy side and its corresponding loca- 
tion on the sick side estimated therefrom. 

The patient should be instructed to sit up and to place the 
arm of the affected side on the opposite shoulder as this broadens 
the intercostal spaces. Then, as a rule, the needle is inserted 
quickly into the fifth or sixth interspace, close to the upper mar- 
gin of the rib to avoid injuring an intercostal artery. 

If necessary local anesthesia may be produced by an ether 
spray or a chloride of ethyl spray, and if it is desired to facili- 
tate the entrance of the needle still more and to reduce the pain 
to a minimum, a small incision through the outer integument in 
the anesthetized area may first be made. The entrance of the needle 
into the pleural cavity can readily be determined by a certain 
"give." 

The fluid is now withdrawn either with the aid of a Potain 
or Dieulafoy aspirator, although these complicated apparatuses 
are rarely necessary. The object of using them is to prevent 
the entrance of air into the pleural cavity. This accident can 
very readily be prevented in a simple manner by connecting the 
trocar with a small rubber tube about three or four feet long 
into the end of which a small funnel is inserted; close to the 
needle a clamp compresses the rubber tube. The funnel, tube 
and needle are filled with a four per cent, boric acid solution, the 
clamp closed, and, during the insertion of the needle, the fun- 
nel held high by an assistant. As soon as the needle enters the 
pleural cavity the clamp is removed and the funnel lowered 
into a vessel containing four per cent, boric acid solution. In 
this way the exudate is removed by direct drainage under slight 
negative pressure and there is practically no danger of air en- 
tering the pleural cavity. The rapidity of the out-flow can be 
governed by the clamp. 

After enough of the fluid has been withdrawn the skin is 
squeezed tightly about the needle and the latter very rapidly ab- 
stracted. The little wound is quickly covered with a piece of 
court-plaster or with a small strip of iodoform gauze that is 
glued to the skin with collodion; usually no other dressing is 
required. 

The amount of fluid to be drained off varies according to 
individual peculiarities of the case and the reaction of the pa- 
tient. Upon the first appearance of syncope the needle should at 



DISEASES OP THE LUNGS AND PLEURA 497 

once be withdrawn and the aspiration of fluid stopped. In very 
large exudates as much as a liter or a liter and a half of fluid 
may be slowly withdrawn with impunity. It will rarely be 
necessan^, however, to take away more than 500 cc. 

After the thoracentesis has been performed the patient should After treat- 
remain in bed, hot applications or counter-irritation (see above) 
should be applied to the chest and diuresis and catharsis stimu- 
lated. At the same time in order to promote the expansion of 
the lung the patient should be instructed to take twenty or thirty 
deep, forced inspirations several times a day, raising the hands 
above the head with each expiratory effort or, better still, he should 
perform expiratory movements against pressure, either in a pneu- 
matic cabinet or simply by slowly inflating a large rubber bag two 
or three times a day. 

If the contents of the pleura is purulent (empyema), or if Empyema and 
air enters the pleura (pneumothorax) through the chest wall pneumothorax 
after trauma or from perforation of a pulmonary or bronchiectatic 
cavity, or possibly from the esophagus, stomach 'or colon as 
the result of ulcerative perforation, then the treatment be- 
comes surgical. 

The only treatment of a purulent pleurisy is free incision and Treatment of 
drainage, if necessary with resection of portions of one or more purulent 
ribs. No case should be considered too desperate to attempt this 
operation, as remarkable improvement is generally seen in these 
cases when drainage is established and the pus is freely evacuated. 
As a precautionary measure thoracentesis may be attempted 
when the services of a competent surgeon cannot at once be se- 
cured, or if the patient is in so reduced a condition that the 
evacuation of some of the pus by means of a trocar is 
deemed a conservative preliminary measure instituted in order to 
give the patient more strength and resisting power to withstand 
the shock of the later operation; or, finally, if it is desired to 
withdraw large accumulations of pus gradually for fear of en- 
dangering the patient's life by suddenly changing the pressure 
equilibrium in the thorax. In all these instances thoracen- 
tesis must, however, always be considered merely as a pal- 
liative and not as a curative measure, notwithstanding the fact 
that very rarely an empyema gets well from simple aspiration 
of pus by tapping. The latter fortunate issue can never be 
counted upon. 

The after-treatment of empyema following evacuation of the 
pus does not differ materially from that employed after thora- 
centesis for simple pleurisy. Special attention should be directed 
toward promoting free expansion of the lungs by forced expira- 
tion exercises against pressure (inflating a rubber bag, blowing 



498 DISEASES OF THE LUNGS AND PLEURA 

bubbles through a water bottle, breathing in a pneumatic chamber, 
etc.), because in purulent pleurisy in particular there is a tendency 
to the formation of tough adhesions that seriously interfere with 
the expansion and aeration of the lung and hence prevent restitu- 
tion to normal conditions. 
Treatment of j n pneumothorax there is usually some fluid in the pleural 

cavity (rarely serous or serofibrinous, generally hemorrhagic or 
purulent) ; so that in many of these cases thoracentesis becomes 
necessary. If in simple pneumothorax the intra-thoracic pressure 
becomes very high so that the dislocation of the thoracic viscera, 
the excessive compression of the lung with great pain, distressing 
dyspnea, venous congestion about the head and the serious inter- 
ference with the heart's action renders the condition of the patient 
unbearable, then puncture of the chest wall may be performed 
for the purpose of allowing the escape of some of the air and 
rendering the pressure within the pleural sac equal to the at- 
mospheric pressure. In valve pneumothorax this procedure may 
have to be repeated at frequent intervals. 

If the pneumothorax develops suddenly from the perforation 
with a sharp pain, profound dyspnea, a weak heart's action, liv- 
idity and symptoms of collapse, then a hypodermic injection of 
one-fourth grain of morphine should be given at once, and re- 
peated if necessary. The heart, at the same time, should be sup- 
ported by analeptics ; hot poultices, a mustard plaster or one of the 
anodyne preparations enumerated above must be applied to the 
chest wall until the most violent symptoms have subsided. The 
subsequent treatment, until thoracentesis or thoracotomy are per- 
formed, does not differ materially from that of any other form 
of pleurisy. 



CHAPTER X. 

DISEASES OF THE DIGESTIVE APPARATUS. 

THE STOMACH. 



ACUTE GASTRITIS. 

Acute gastritis, whether due to over-eating or to the ingestion 
of indigestible articles that irritate and overtax the stomach, or 
to alcohol, or to infectious agencies, calls for rest of the stomach 
and prompt evacuation of the offending material. As a rule these 
two postulates are promptly fulfilled by Nature, inasmuch as the- 
patient both manifests a violent aversion for food and promptly 
responds to the ingestion of food by nausea and vomiting, or vomits 
spontaneously. Many cases of acute gastritis recover within a 
few days if not interfered with, especially if they receive neither 
food nor medicine. 

During the period of enforced or voluntary fasting most of the 
patients complain only of thirst, and this should be appeased either 
by repeatedly washing out the mouth (a procedure that is especially 
agreeable to the patients on account of the bad taste and bad breath 
that usually accompanies acute gastritis) with some simple mouth 
wash (see index), or by swallowing ice pills or teaspoonful doses of 
ice water, ice cold lemonade or orangeade, or very dilute hydro- 
chloric acid. Small swallows of ice cold carbonated waters are par- 
ticularly agreeable and soothing to the stomach, because the alkali 
of the water aids in dissolving the mucus and the carbonic acid 
exercises a slightly anesthetic effect upon the irritable mucous lin- 
ing of the stomach. 

Should the stomach not spontaneously get rid of its contents 
by vomiting, then the evacuation of the stomach contents should be 
artificially promoted either by producing emesis or preferably by 
lavage. 

The ordinary emetics, as ipecac, tartar emetic, etc., should 
never be given by mouth on account of the irritating effect they 
exercise upon the already hyperemic gastric mucosa; besides, they 
take considerable time to produce their effect, and delay may be 
dangerous, especially in children. Sometimes such simple measures 
as drinking lukewarm water, tickling the pharynx with the finger, 



Evacuation of 
the stomach 



Abstinence 
from food 



To control 
thirst. 



Emetics 
Ipecac 
Tartar emetic 



Lukewarm 
water, 



500 



DISEASES OE THE DIGESTIVE APPARATUS 



Apomorphine 



Lavage 



Apparatus to 
be used 



Introduction 
the stomach 
tube 



of 



Expression 



are effective in producing vomiting, especially in patients who vomit 
easily. Some people, however, vomit with great difficulty, or fail 
to vomit at all with the aid of these simple measures, then the 
stomach contents is not completely evacuated; under such circum- 
stances apomorphine given hypodermically, in watery solution, in 
the dose of a twentieth to a tenth of a grain (3 to 6 mg.), repeated, 
if necessary, is a useful remedy. 

Best of all, however, is lavage of the stomach either with warm 
water or, better still, with a dilute soda solution containing one 
teaspoonful of soda to the quart of water ; for the soda aids in dis- 
solving the mucus that coats the inner gastric walls. 

Many kinds of apparatus have been devised for performing 
lavage of the stomach. It is unnecessary to employ the compli- 
cated systems of funnels, tubes, clamps and glass connections that 
have been described. The latter are chiefly useful in the treat- 
ment of chronic gastric disorders, and for use by the patient 
himself, or by the inventor of the device. 

For ordinary use at home a simple stomach tube and a glass 
funnel, or a stomach tube with an aspirating bulb, are the most 
convenient and the simplest to employ. If the funnel is used, the 
stomach contents is removed by siphonage; if the bulb is used, by 
aspiration. The tube should be smooth and soft. Stiff tubes with 
longitudinal ridges should not be used. 

The introduction of the stomach tube should never be attended 
with much difficulty. Inasmuch as it is usually more difficult for 
the physician and less agreeable to the patient to have the stomach 
tube passed in the recumbent than in the upright position, it is 
best, especially if lavage of the stomach is being performed for the 
first time, to have the patient sit up opposite to the physician with 
the head slightly bent forward. Before introducing the stomach 
tube the manipulation that it is intended to perform should be 
carefully explained to the patient and assurance should be given 
that the tube will be promptly withdrawn if it does not slide down 
easily, or if it produces gagging or choking. In excitable or nerv- 
ous subjects the physician should continuously speak to the patient, 
encourage him to breathe deeply and to keep his mouth open and 
perform swallowing movements until the tube enters the stomach. 
The tube should be moistened with water (not with oil, vaseline 
or glycerin) and advanced to the pharyngeal wall; the patient 
should then be told to perform swallowing movements, with the 
head bent slightly forward and to continue swallowing while the 
physician pushes the tube down until it reaches the stomach. 

The patient may now attempt to express the stomach contents 
by retracting the abdominal muscles and straining; in this way a 
large porportion of the offending material may often be evacuated. 



DISEASES OF THE DIGESTIVE APPARATUS 



501 



If this manipulation does not bring out any of the stomach con- 
tents, then a large funnel holding about 500 cc. should be inserted 
into the free end of the stomach tube and held about two feet above 
the patient's mouth and a dilute soda solution (see above) poured 
into it. As soon as most of the fluid has passed down, the fun- 
nel should be lowered below the level of the stomach and the con- 
tents removed in this way by siphonage. This manipulation should 
be repeated several times until the wash water comes out clear. If 
the patient shows considerable tolerance for the stomach tube, then 
it is well to have him lie down with the tube in place and to per- 
form lavage again in the recumbent position. It will often be 
found that in this way considerable material will be removed from 
the stomach, even if the wash water came out quite clear while 
the patient was sitting up. In order to avoid retention of the 
wash water in the stomach it is best to catch the water returning 
from the stomach in a graduated vessel and to measure carefully 
the amount of water poured in and the amount recovered from 
the stomach. 

If the water is poured into the funnel too quickly a vortex is 
often formed and, in this way, considerable air is sucked into the 
stomach; when this occurs the funnel should be held in a slant- 
ing position at once, and the aspiration of air will stop. Quite 
frequently when the patient begins to perform vomiting move- 
ments the wash water pours out alongside the tube; this is due 
either to pouring the water in too quickly or under too great pres- 
sure; the remedy, therefore, is to pour the water more slowly and 
to lower the funnel. If the tube has been pushed in a little too 
far so that it touches the sensitive mucosa at the fundus, then vom- 
iting and retching may also occur; here withdrawal of the tube 
an inch or two will frequently stop the patient's distress and the 
pouring out of water through the mouth. 

The tube should be withdrawn with some water still in the 
funnel. It is always dangerous to let all the water run out of the fun- 
nel as, in this way, considerable air may be pumped into the stomach 
upon a second washing or in withdrawing the tube some of the 
mucosa may be pulled off. In removing the tube, therefore, it 
should be withdrawn with the water still flowing until its lowest 
point is well above the cardia. As soon as the tip of the tube is 
out of the stomach, the tube should be compressed below the fun- 
nel and drawn out quickly. 

Many of the accidents and disagreeable complications spoken 
of above can be avoided by using an aspirating bulb instead of 
a funnel. The tube is inserted as described above, the aspirating 
bulb compressed and attached to the open end of the stomach tube 
and then allowed to expand, and in this simple way the stomach 



Jyphonage 



Lavage in re- 
cumbent posi- 
tion 



Accidents to be 
avoided 



Withdrawing 
the tube 



Aspiration 



502 



DISEASES OE THE DIGESTIVE APPARATUS 



Laxatives 

Castor oil 
Calomel 



Diarrhea 



Constipation 



Bowel irriga- 
tion 



Pain 

Priessnitz 
compress 



Heat 



Morphine 

Belladonna 

Cocaine 



contents aspirated. In order to perform lavage with, the aspirating 
bulb the bulb is filled with water, the water pressed into the stomach 
and removed immediately by allowing the bulb to expand ; the tube 
should be withdrawn with the bulb expanded. 

Evacuation of the stomach contents usually brings prompt re- 
lief. Often spoiled or fermenting food has passed on into the bowel 
before the stomach contents is evacuated, then emptying of the 
bowel may also become necessary. This is best brought about by 
the use of castor oil in tablespoonful doses; for the latter (aside 
from frequently producing nausea and thereby emesis) exercises 
a rapid purgative effect. Calomel, too, is a useful remedy in these 
cases, for it acts as a cholagogue, a rapid evacuant and an antiseptic. 
It should be given in doses or two to three grains (0.13 to 0.2 gm.), 
or in several doses of a half gTain (0.03 gm.) every hour for four 
or five doses, followed within a few hours after the administration 
of the last dose by a tablespoonful of castor oil or a saline laxative. 

This practice usually stops the diarrhea that is apt to supervene 
if evacuation of the irritating bowel contents is not promptly 
brought about. It also successfully conteracts the obstinate con- 
stipation that sometimes complicates acute gastritis. It is always 
had practice to attempt to check the diarrhea by the use of opiates, 
tannic acid or other anti-diarrheic remedies before complete evacua- 
tion of the putrid bowel contents has been promoted. 

In addition to producing evacuation of the bowel by the ad- 
ministration of castor oil or calomel by mouth, bowel irrigation 
with oil or with glycerin in water or soapsuds in water is very 
useful. By cleansing the lower bowel the colicky pains are often 
relieved, for the latter are chiefly produced by the increased peri- 
staltic movements of the small intestine and are rendered more se- 
vere if an obstacle to the evacuation of the bowel contents is offered 
by impaction of the colon with solid fecal material. 

The pain and the distress in the epigastric region usually dis- 
appear within a day or two if the above measures are adopted. If 
the pain persists or is very severe, a Priessnitz compress applied to 
the epigastrium generally acts as an effective counter-irritant and 
analgesic. Such a compress is applied by laying a linen cloth, 
wrung out of cool water, upon the epigastrium and covering it with 
a piece of flannel. This application should be repeated every two 
or three hours. Sometimes a hot water bag over the stomach or 
a thermophore (see index) are grateful to the patient. In ex- 
treme cases with much pain and very persistent vomiting a hypo- 
dermic of an eighth of a grain of morphine with a two-hundredth 
of atropine, or opium with belladonna in suppository of the ex- 
tract each % gr., may have to be given; or if there is very much 



DISEASES OF THE DIGESTIVE APPARATUS 503 

hyperesthesia of the gastric mucosa, cocaine as described (see in- 
dex) may be administered. 

After a period of starvation lasting for twenty-four to forty- Diet 
eight hours some food should, by all means, be administered. The 
diet should at first be liquid and cold and should be given in small 
quantities, beginning with teaspoonful doses of cold milk or thin 
gruels made with water or milk, possibly with an egg stirred in. 
Later, as the patient recovers, easily digestible foods should be ad- 
ministered in gradually increasing quantities. 

THE DIGESTIBILITY OF FOODS. 

This question of digestibility is a difficult one. As a rule the 
criterion of digestibility is considered to be the length of time 
that an article of food remains in the stomach, and a number of 
tables have been arranged by different clinicians, giving a scale 
of digestibility based on this standard. The following, by Pent- 
zoldt, is one of the most reliable, and has the advantage, moreover, 
of giving the quantities of the different foods: 

The stomach normally empties itself of the following articles 
in the time named: 

SCALE OF DIGESTIBILITY. 

Within one or two hours. 
100-200 cc. water, pure. 
200 cc. water, carbonated. 
200 cc. tea. 
200 cc. coffee. 
200 cc. cocoa. 
200 cc. beer. 
200 cc. light wine. 
100-200 cc. milk, boiled. 
200 cc. meat broth without additions. 
100 gm. eggs. 

Within two or three hows 
200 cc. coffee with cream. 
200 cc. cocoa with milk. 
200 cc. malaga wine. 
300-500 water. 
300-500 beer. 
300-500 milk, boiled. 

100 gm. eggs, raw, hard boiled, or as omelette 
100 gm. beef, raw sausage. 
250 gm. calf s brains, boiled. 
250 gm. sweetbreads, boiled. 



504 DISEASES OF THE DIGESTIVE APPARATUS 

72 gm. oysters, raw. 
200 gm. carp, boiled. 
200 gm. pike, boiled. 
200 gm. codfish, boiled. 
150 gm. cauliflower, boiled. 
150 gm. cauliflower, salad. 
150 gm. potatoes, boiled. 
150 gm. mashed potatoes. 
150 gm. stewed cherries. 
150 gm. raw cherries. 

70 gm. white bread, fresh and stale, dry or with tea. 

70 gm. zwieback, fresh and stale, dry or with tea. 

Within three or four hours. 

230 gm. young boiled chicken. 
220-260 gm. squab, boiled. 
195 gm. squab, roast. 
230 gm. partridge, roast. 
220-230 gm. young chicken, roast. 
250 gm. beef, raw, boiled (lean). 
250 gm. calf's feet, boiled. 
160 gm. ham, raw and boiled. 
100 gm. veal, warm and cold (lean). 
100 gm. beefsteak, broiled, cold and warm. 
100 gm. beefsteak, raw, scraped. 
100 gm. roast beef. 
72 gm. caviar, salt. 
150 gm. brown bread. 
150 gm. Graham bread. 
150 gm. white bread. 
100-150 gm. Albert biscuits. 
150 gm. potatoes, vegetable. 
150 gm. rice, boiled. 
150 gm. carrots, boiled. 
150 gm. spinach, boiled. 
150 gm. cucumber salad. 
150 gm. radishes, raw. 
150 gm. apples. 

Within four or five hours. 

210 gm. squab, broiled. 
250 gm. fillet of beef, roast. 
250 gm. beefsteak, broiled. 
250 gm. beef tongue, smoked. 
250 gm. rabbit, roast. 



DISEASES OF THE DIGESTIVE APPARATUS 505 

240 gm. partridge, roast. 

250 gm. goose, roast. 

280 gm. duck, roast. 

200 gm. salt herring. 

150 gm. lentil puree. 

150 gm. string beans, boiled. 

The length of time during which an article of food remains Definition of 
in the stomach is not, however, the only measure of its digestibility, lges 1 ll y 
especially in pathological cases; for, broadly speaking, an article 
of food may be considered digestible, first, if it produces no dis- 
agreeable subjective symptoms; second, if it does not overtax either 
the motor or the secretory powers of the stomach. The element of 
idiosyncrasy also enters into the equation here; for an article may 
be very well digested in the stomach but not be well borne by the 
patient or, on the other hand, it may be well borne, i. e., cause 
no subjective symptoms of distress and still may leave the stomach 
in a practically undigested form to undergo, finally, disassimilation 
in the intestine. In either case the article must, insofar as the 
stomach is concerned, be considered indigestible, for it fails to meet 
the prime requirements of a digestible article, i. e., neither to 
over-tax the motor, the secretory or the sensory function of the 
diseased organ. In pathological cases where the perversions of 
these three functions are frequently associated this applies with 
particular force, as will be shown later when discussing chronic 
disorders of the stomach and the functional perversions of the 
organ. 

In this place, however, some general considerations in regard 
to the utility of different foods in stomach disorders, i. e., their 
digestibility in a broader sense, may be inserted. 

The digestibility of meats depends upon their origin, upon the Digestibility 
amount of fat they contain and their mode of preparation. The °* meats 
most digestible varieties of meat are poultry, especially chicken and 
squab ; less digestible are duck and goose. Veal, if sufficiently aged 
(see below) and properly prepared, comes next in the stage of di- 
gestibility, then fish with the exception of the fat varieties * like 
trout, mackerel, pickerel and salmon ; less digestible than the above 
are beef, pork and mutton. 

The more fat meat contains the less digestible it is; for fat is The fat of 
not at all digestible by the juices of the stomach and as it surrounds meat 
the muscle fibers it protects them from the action of the gastric 
juices, so that a large proportion of the albuminous constituents 
of fat meat pass from the stomach into the intestine practically un- 
digested. 



506 



DISEASES OF THE DIGESTIVE APPARATUS 



Raw meat and 
cooked meat 



Methods of 
cooking meat 



Smoked, cured 
corned meats 



Fresh and 
"hung" meat 



'High" meats 



Broths 



Raw meat is more digestible than meat cooked in any way, es- 
pecially if it is chopped or scraped, for in this manner the con- 
nective tissue fibers are torn and macerated and free access to the 
muscle tissue is given to the gastric juice. Rare meats are always 
more easily digested than meats that are well done. 

Boiled, stewed or roast meats are about equally digestible ; their 
nutritive value, however, varies according to the method of cook- 
ing. If the meat is placed at once into boiling water, the albumens 
on the surface are promptly coagulated, so that the nutritive in- 
gredients of the meat are retained. If it is intended to make stew; 
i. e., to extract the nutritive ingredients, then the meat should, of 
course, be placed into cold water which is gradually heated to the 
boiling point. The same principle obtains in roasting meat; it 
remains most nutritious if it is exposed at once to great heat, for 
in this way the coagulate that forms on the outside prevents the 
nutritive juices from running out into the pan. 

Smoked, cured and corned meats are less digestible than raw 
or cooked meats, because they contain creosote and similar prod- 
ucts that are generated during the process of smoking and curing, 
and these creosote preparations materially interfere with digestion. 
The large amount of salt contained in salt meats and fish is also 
detrimental, so that the digestibility of the latter foods must be 
estimated as low. 

Meat in order to be digestible should not be too fresh, for, if 
eaten within a few hours after the animal is killed, i. e., while 
the muscle tissue is still in a state of rigor mortis, the coagulated 
myosin renders the meat fibers difficult of digestion. After hang- 
ing for a time lactic acid forms and softens the connective tissues 
while bacteria cause dissolution of the myosin coagulate. The 
meat should, of course, not hang too long nor in too warm a tem- 
perature, as otherwise putrefactive processes may set in with the 
formation of ptomaines. "High" game and poultry, therefore, are 
very detrimental in any stomach disease. As poultry is eaten al- 
most immediately after it is killed, i. e., before myosin coagula- 
tion occurs, both the above difficulties are usually obviated. 

Meat broths contain salts, extractives, kreatinin, gelatin, a lit- 
tle albumen and peptones, hardly any fat, and water; their nu- 
tritive value, therefore, is very small. They act chiefly as stimu- 
lants to the flow of gastric juice and, through the extractives they 
contain, as stimulants to the nervous system and the circulation. 
Unless contra-indicated by conditions of the stomach in which it 
is desired not to dilute the gastric juice or to over-tax the weak 
gastric musculature by the ingestion of much fluid, meat broths 
fulfill a useful purpose. 



DISEASES OF THE DIGESTIVE APPARATUS 507 

So-called peptones and different predigested foods contain Albumoses and 
albumoses; the latter are more easily assimilable than native albu- pep ones 
men, and they can replace albumens to some extent. Inasmuch, 
therefore, as they are nutritious and non-irritating to the stomach 
wall they serve a useful purpose, especially in gastric catarrh. Their 
taste unfortunately is disagreeable to many people and occasionally 
they produce diarrhea. 

Gelatinous foods, in small quantities, are a very useful addi- Gelatin 
tion to the diet in the form of gelatin, aspic, meat jellies, calves' 
head, etc.; they are non-irritating to the stomach, but also oc- 
casionally produce diarrhea. 

The digestibility of eggs depends exclusively upon their mode Eggs 
of preparation. Soft boiled eggs and eggs stirred in soups or 
poached very soft are the most digestible of all; raw eggs, fried 
eggs and hard boiled eggs the least digestible. The white of egg 
is more digestible than the yolk on account of the fat that the lat- 
ter contains. A very digestible and very nutritious preparation is 
a watery solution of egg albumen with a little salt. 

Milk constitutes a very nourishing, digestible and non-irritat- Milk 
ing food, so that it should occupy a large place in the dietary of 
stomach cases. Some people possess a distinct idiosyncrasy against 
milk, manifesting not only a thorough distaste for it in any form, 
but also an inability to properly digest it. The latter difficulty 
may occasionally be overcome by the addition of lime water, soda, 
magnesia or brandy, all ingredients that are intended chiefly to 
change the character of the curds that form in the stomach. If 
milk cannot be taken, buttermilk, kephyr, kumyss or solutions of 
condensed milk serve an equally useful purpose. There is no dif- 
ference in digestibility between raw or boiled milk. 

Inasmuch as milk, as shown in a previous section, cannot fulfill Gruels 
the caloric requirements of an individual if given as the exclusive 
article of diet, it is best to add to it certain cereals, as wheat, bar- 
ley or oatmeal flour, rice, sago, tapioca, or one of the many dex- 
trinized foods that are on the market. The addition of these vari- 
ous substances in no way renders the milk less digestible and ma- 
terially adds to its nutritive value, so that the patient can subsist 
for a long time upon gruels made with milk in this way. 

Among vegetables, potatoes and other vegetables growing under Vegetables 
ground and those growing in pods are most nutritious and most 
digestible, especially if served boiled in water or, best of all, mashed 
or as purees. Leafy vegetables are not very nutritious, contain 
abundant cellulose, which is not at all digestible, and frequently 
acids, which may be harmful in diseases of the stomach. Salads, 
therefore, prepared with oil, vinegar and spices are to be especially 
avoided in stomach diseases; for the character of the leaves from 



508 



DISEASES OF THE DIGESTIVE APPARATUS 



Fruits 



Nut emulsions 



Bread stuffs 



Sugar 



which the salads are made, the fat, the acid and the spices all ren- 
der salad harmful. Very digestible and nutritions vegetables are 
cauliflower, asparagus (especially the heads), spinach and string 
beans. 

Fruits should be given sparingly in stomach diseases, for they 
contain abundant cellulose, free acids and much sugar and are 
very commonly contaminated with bacteria. The least harmful 
fruits are apples and pears, better given stewed than raw. Grapes, 
too, are very useful. Berries on account of the seeds and acids they 
contain, cherries, plums and peaches on account of the acids and 
abundant cellulose, are not very good. Nuts are very indigestible. 
A useful preparation of nuts, however, is so-called nut-milk made 
from ground almonds or other nuts mixed with four or five parts 
of water and two or three parts of milk. Such nut emulsions are 
very soothing to the stomach and are also nourishing on account 
of the albumens, fats and sugar they contain. 

Of bread stuffs the best are toast, crackers and zwieback. Stale 
bread is always better digested than fresh bread, especially hot 
bread. The crust of bread is by far preferable to the soft por- 
tions; for the former is better dextrinized and hence partially pre- 
digested and, moreover, requires more thorough mastication, hence 
preliminary dextrinization in the mouth, than the soft part of the 
bread. Breads made of coarse flours require a very active gastric 
juice and should never be given if the gastric function is weak; 
they have a distinct place, however, in the treatment of some gastro- 
intestinal diseases, especially where it is desired to stimulate peri- 
stalsis of the intestine. The so-called diabetic breads described 
earlier herein are digestible and nutritious without being irritating 
to the stomach, hence they are very useful in stomach disorders. 

Sugar is introduced either in the form of cane sugar in ordi- 
nary table sugar and some vegetables; or as dextrose or levulose 
in grapes, honey and certain fruits; and as lactose in milk. Inas- 
much as dextrose and levulose are absorbed directly and rapidly, 
whereas cane sugar must first be split (inverted into dextrose and 
levulose, before it can be absorbed, it is clear that the administration 
of the former sugars is more rational than that of cane sugar; for 
the latter is forced to remain in the stomach and upper portion of 
the bowel longer than dextrose or levulose; hence fermentation is 
more apt to occur with gaseous distention of the stomach and 
bowel if cane sugar is given than if sugar is administered in the 
form of dextrose or levulose. It has been established moreover, that 
cane sugar retards the digestion of the albumens and fats to some 
extent. In stomach diseases, therefore, cane sugar should be given 
sparingly and the demands of the patient for sweet foods should 
largely be satisfied by the administration of honey or dextrose. 



DISEASES OF THE DIGESTIVE APPARATUS 509 

The digestibility of fats is approximately proportionate to their Fats 
melting point ; the lower the melting point the more digestible they 
are as a rule; thus vegetable oils and the milk fats, i. e., butter 
and cream and milk, are by far more digestible than animal fats. 
The digestibility of the latter, moreover, is impaired by 
the fact that the fat substance is enclosed in a tough cell mem- 
brane. 

Of beverages, water in large quantities should always be Beverages 
avoided in stomach diseases, for it taxes the motor power of the 
stomach, retards digestion and dilutes the gastric juice. Sufferers 
from stomach disorders should, therefore, refrain from drinking 
much water immediately before, during or after meals. 

The use of coffee in stomach cases must be largely governed by Coffee 
the reaction of the patient. Tea and coffee, per se, exercise no Tea 
effect upon gastric digestion, itself. In some persons they act 
upon the nervous apparatus, producing certain symptoms about 
the higher cerebral centers and also somewhat stimulating peristal- 
sis. The prejudice against coffee and tea in stomach diseases 
is largely exaggerated. If a choice is to be made between the 
two, tea, empirically, is probably less harmful than coffee. It is 
generally a superfluous restriction to forbid the use of small 
quantities of coffee, especially for breakfast, to people who have 
been used to this beverage all their lives. 

The use of small quantities of alcoholic beverages is generally Alcohol 
helpful in stomach disorders. That alcohol in any form should 
be avoided in acute gastritis need hardly be emphasized, but in 
more chronic varieties of stomach disorders, especially in certain 
functional disturbances, small quantities of alcohol act as a stimu- 
lus to the motor power and the secretion of the stomach, increase 
the appetite and materially aid in the digestion of fats by promoting 
the evacuation of the latter from the stomach. It is true that 
alcohol precipitates pepsin, but this disadvantage is more than 

overbalanced by the advantages enumerated above. Most cases „lt n 1 q 1 
J to ueurs, claret, 

of chronic stomach trouble are benefited by the use of a moselle 
little brandy, a liqueur or Sherry after meals or by drinking 
a glass or two of light Claret, Burgundy or Moselle wine during 
their meals. 

Cider on account of the large quantity of acid it contains is Cider 
not so useful a beverage. Beer should be forbidden, for it con- Beer 
tains abundant carbonic acid gas which distends the stomach, 
especially as it is always taken in relatively large quantities, 
hence violates the principle of restricting the liquid intake dur- 
ing and before meals. Beer, moreover, unless pasteurized, con- 
tains yeast cells which are very apt to set up fermentative processes 
in the stomach and bowel. Small quantities of champagne Champagne 



510 



DISEASES OF THE DIGESTIVE APPARATUS 



are useful both on account of the alcohol and the carbon 
dioxide they contain. Large quantities should, however, never 
be given because of the danger of distending the stomach from the 
rapid evolution of gas. 
Smoking Smoking, finally, should never be permitted in acute gastric 

disorders. In other gastric troubles it should never be allowed 
when the stomach is empty, for it undoubtedly reduces the ap- 
petite. A cigar or two a day, however, especially in men who 
have been accustomed to the use of tobacco all their lives, in- 
dulged after meals can do no harm and it is a cruel and unnec- 
essary restriction to dogmatically forbid the use of tobacco iD 
every case of stomach disorder. 



CHRONIC GASTRITIS. 



Causes 



Causal and 
propylactic 
treatment 



Chronic gastritis may develop consecutively to a number of 
primary disorders about the heart, the liver, the kidneys and the 
lungs. In all these conditions disturbances of the circulation lead- 
ing to venous stasis in the stomach or portal stasis are responsi- 
ble for the gastric catarrhal symptoms. In many metabolic dis- 
orders, in severe anemia and leukemia, chronic gastritis is an im- 
portant phenomenon. Chronic gastric catarrh may also ac- 
company certain organic diseases of the stomach like carcinoma, 
ulcer, ectasy. 

Chronic gastritis does not invariably accompany these differ- 
ent diseases, hence the existence of special factors must be postu- 
lated in many cases that determine the development of catarrh. 
Chief among the latter are any of the agencies that have been enu- 
merated in the preceding section as producing acute gastritis, 
especially if these agencies remain operative for a long time. In- 
discretions in diet, that is, eating the wrong food or too much food, 
fast eating, failure to properly masticate the food, the abuse of 
alcohol, the excessive use of spices, of hot foods and of medicines, 
chiefly purgatives, can all cause chronic gastric catarrh. All these 
factors may also produce chronic gastritis without the presence 
of any of the general disorders mentioned above, either by causing 
acute gastritis, which is neglected, or which frequently recurs and 
finally becomes chronic, or by producing slow, gradual involve- 
ment of the gastric mucosa, so that chronic gastritis insidiously 
develops. 

In instituting causal and prophylactic treatment in chronic 
gastritis all these elements must be considered. Any circula- 
tory disorder that may be present must be corrected, if possible, 
by the use of all those measures that can counteract venous stasis 



DISEASES OF THE DIGESTIVE APPARATUS 



511 



in the general circulation and chiefly in the portal area. The 
renal pulmonary, metabolic, hematic disorders that may be pres- 
ent must be carefully treated as described in other sections. 

In chronic gastric catarrh two elements predominate, there 
is first an excessive secretion of mucus and second, a perversion 
of the gastric secretion generally manifesting itself by a deficient 
outpouring of digestive ferments and of hydrochloric acid; (in 
rare cases, however, there may be hyperchlorhydria). The food 
introduced into the stomach owing to these abnormal conditions 
fails to undergo proper disassimilation and hence stagnates, espe- 
cially as the chronic inflammation of the stomach wall often leads 
to weakening and atony of the gastric musculature; consequently 
abnormal fermentation of the gastric contents commonly occurs 
and the condition is further aggravated by the formation of irri- 
tating poisonous acids, ptomaines and gases. 

The indications for treatment are to remove the mucus; to 
correct the perversion of secretion; to administer a diet that 
spares the gastric function and that can be promptly propelled 
onward into the intestine; to remove the irritating products of 
fermentation; and, last of all, to stop the fermentative processes, 
so far as that can be accomplished, by the use of appropriate meas- 
ures. 

In order to remove the mucus, lavage is the sovereign remedy. 
In chronic gastritis the stomach should be washed persistently. 
In mild cases, lavage in the morning before breakfast is usually 
sufficient; at this time any stagnating contents that may have re- 
mained in the stomach overnight has become decomposed and 
softened, so that it is easily removed with the stomach washings. 
At all events at this time any food material that may still be pres- 
ent in the stomach no longer possesses much nutritive value, so 
that it is best removed. It is, moreover, a precarious procedure 
to introduce fresh food into a stomach that contains fermenting 
and decomposed material from the previous day. 

In some cases of gastric catarrh in which the motor power of 
the stomach is sufficiently good to cause the evacuation of all the 
stomach contents during the night, it may be better to perform 
lavage six or seven hours after the main midday meal, especially 
as these patients suffer the greatest distress and discomfort at 
such time. In this way much of the mucus is removed and the 
stomach is relieved of labor that it is manifestly unable to per- 
form, for, normally, the stomach should be empty at this time. 
If the stomach contents is removed late in the afternoon, then the 
patient should receive a very light evening meal. 

In another variety of cases the patients complain of the great- 
est distress at night; this occurs particularly if the heaviest meal 



General indi- 
cations for 
treatment 



Lavage 



Lavage in the 
morning 



Lavage in the 
afternoon 



Lavage in the 
evening 



512 



DISEASES OF THE DIGESTIVE APPARATUS 



Irrigation 
fluids 



Alkalies 
Salt 



Antiseptics 
Potassium per- 
manganate, 
salicylic acid, 
thymol, hydro- 
chloric acid 



Technique of 
lavage in 
chronic gas- 
tritis 



Contra-indica- 
tions to use of 
stomach tube 



Mineral waters 



is eaten in the evening and the patients go to bed three or four 
hours after their dinner. Here distention of the stomach with 
gases, sour eructations, epigastric pain, awaken the patients in 
the night and seriously interfere with sleep and hence general 
nutrition. In such cases it is best to perform lavage of the stom- 
ach just before the patients retire for the night. 

In many cases, finally, it may be necessary to perform lavage 
both in the morning on rising and six hours after the main meal, 
or in the morning and on retiring. 

If there is onlv little mucus, simple water of body temperature 
may be used. In some cases, however, it is advantageous to use 
an alkaline or saline solution containing two teaspoonfuls of sodi- 
um carbonate to a litre, or five teaspoonfuls of lime water to a 
litre, or ten grammes of common salt to a litre, or a teaspoonful 
of a mixture of two parts of common salt and one part of sodium 
carbonate to the litre. The alkalies aid materially in dissolving 
the mucus and also in neutralizing the acids that are formed by 
fermentation. 

The addition of antiseptic remedies to the wash water can do 
no harm. Very useful solutions are potassium permanganate, 
0.1 to 2,000; salicylic acid, 1:1,000; thymol, 1:2,000; hydrochloric 
acid, Hive drops to 1,000. 

The evacuation of the stomach mucus can be further aided by 
forcing the water into the stomach under considerable pressure, 
i. e., either by holding the funnel high above the mouth, or better 
still, by using the stomach tube and aspirating bulb and exercis- 
ing considerable pressure upon the bulb when the water is forced 
into the stomach. Lavage should be continued until the wash 
water comes out quite clear. In some cases it will be necessary 
to wash the stomach out with the patient sitting erect and also 
lying down. In chronic gastritis, in which the patients soon be- 
come accustomed to the use of the stomach tube, there is no diffi- 
culty in keeping the tube in place while the patient changes his 
position. 

There are distinct contra-indications to the use of the stomach 
tube, namely, advanced arterio-sclerosis, heart lesions in stages of 
pronounced decompensation, esophageal varices, aneurism,* angina 
pectoris and great hyper-excitability or pronounced general debil- 
ity of the patient. If any of the above named conditions exist, 
so that the use of lavage must # be reluctantly abandoned, then min- 
eral waters must take the place of gastric lavage. 

Mineral waters may, of course, also be used in combination 
with lavage in any subject. They act very much like lavage, with 
the difference that the mucus and the fermenting material that they 
dissolve is washed into the intestine instead of being removed by 



DISEASES OF THE DIGESTIVE APPARATUS 



513 



the mouth. The use of mineral waters is, therefore, by no means 
so valuable nor are the results from their employment to be com- 
pared with those obtained from washing out the stomach. If 
there is much motor insufficiency, the ingestion of abundant water 
is, moreover, distinctly contra-indicated. Much harm can be done 
from the routine use of so-called water cures. 

Part of the benefit accruing to stomach cases from the use of 
the various mineral waters must be attributed more to the life at 
the resorts in which these waters are taken than to any of the 
healing properties of the waters themselves; for sufferers from 
digestive disorders who go to a watering place lead a life of great 
regularity among pleasant surroundings, free from the worry and 
routine of their daily existence; they are careful in their diet and 
are, above all, under the supervision of physicians who are especial- 
ly skilled in the treatment of this class of diseases. 

In many of the resorts routine regulations are given the patients 
in regard to their diet, and they are told, often on printed slips, 
what to eat and what not to eat during their water cure. Broadly 
speaking these restrictions are all theoretically constructed and no 
special dietetic restrictions need, as a rule, be observed when the 
different waters are taken that would not be observed if no water 
cure were being instituted. The chief danger lies in the 
drinking of too much water and in drinking large quan- 
ties of water too rapidly, most patients imagining that if a lit- 
tle of the waters will do them good, a great deal must do 
them more good ; and they are generally encouraged in this be- 
lief by the attendants and occasionally by the physicians in these 
resorts. 

The chemical ingredients of the different waters determine 
their use in different conditions. Alkaline waters aid in dissolv- 
ing the mucus, in combining the organic acids that are formed by 
fermentation in the stomach and by increasing intestinal peris- 
talsis. They, as well as the alkaline saline waters, are especially 
useful in atonic and secondary catarrh of the stomach. Alkaline 
waters alone have their particular field of application in chronic 
hyper-acidity with catarrh. Saline waters, which should 
never contain more than ten per cent, of sodium chloride, 
stimulate the formation of hydrochloric acid and of the diges- 
tive ferments, and also excite the motor power of the stom- 
ach and to some extent the appetite. They are especially useful, 
therefore, in cases with hypo-secretion and slight motor insuf- 
ficiency. 

Waters containing Glauber salts, and sulphur waters, as well 
as the bitter waters, are useful, particularly when gastric catarrh 
is accompanied by obstinate constipation and abdominal plethora. 



Resort treat- 
ment 



Dangers of 
routine in re- 
sorts 



Alkaline 
waters 



Saline waters 



Sulpho-saline 
waters 



514 



DISEASES OF THE DIGESTIVE APPARATUS 



Lime waters 



Carbonated 
waters 



Temperature 
of the waters 



Diet 



Proportion of 
carbohydrates 
fats, proteid 



As they are somewhat irritating to the stomach, their use is limited 
in gastric disorders. 

Lime waters act like the alkaline waters, i. e., they are useful 
on account of their antacid and mucus dissolving properties. 

The carbonic acid that many waters contain causes prompt 
belching of carbonic acid gas and this occasionally aids materially 
in the expulsion of fermentative gases that are accumulating in the 
stomach. The carbonic acid gas, moreover, acts as an anes- 
thetic to the gastric mucosa in painful complications of the 
stomach, slightly stimulates the appetite and increases intestinal 
peristalsis. Carbonated waters should, of course, never be used 
in motor insufficiency and gastric atony, for here, precisely, dis- 
tention of the stomach is to be avoided. The same applies to 
cardiac or respiratory diseases in which the stomach function is 
perverted, for here, too, distention of the stomach and bowel, by 
interfering with the respiratory excursions of the diaphragm, and 
hence by imposing more labor upon the right heart, is to be 
avoided. 

The following rule may be formulated in regard to the tempera- 
ture at which these different mineral waters should be taken: If 
there is some motor insufficiency with decreased secretion of gas- 
tric juice and a tendency to constipation, then the mineral wa- 
ters should be taken cold. If the gastric and intestinal mucosa 
is very irritable, and if there is a tendency to diarrhea, then 
warm or hot mineral waters are more grateful to the patient and 
probably more useful. 

No fixed directions can be given in regard to the diet in cases 
of chronic gastritis. In each case repeated analyses of the stom- 
ach function should be made and .the diet arranged according to 
the secretory and motor powers of the stomach, as described in 
subsequent sections. At the same time, in view of the fact that 
chronic gastritis is usually a disorder of long duration, every en- 
deavor should be put forward to maintain full nutrition of the 
patient by supplying sufficient calories in the food. In most 
cases of chronic gastritis the presence of mucus (which covers the 
gastric walls and becomes intimately mixed with the food, thus 
preventing to some extent the outpouring of gastric juice and its 
mixture with the food) as well as the reduction of the hydro- 
chloric acid, will have to be considered. Hence the food should 
be finely divided, thoroughly masticated and insalivated in order 
to impose as little labor as possible upon the stomach digestion 
and to facilitate the prompt removal of the food onward into the 
intestine. 

The carbohydrates in the diet should preponderate, espe- 
cially if there is any motor insufficiency; for they undergo diges- 



DISEASES OF THE DIGESTIVE APPARATUS 515 

tion almost exclusively in the intestine. The same applies to fats 
and the latter should be supplied in the form of digestible varie- 
ties of fats, i. e., milk fat or vegetable oils. Enough proteid 
should be supplied in the form of digestible meats (see preceding 
table) to meet the nitrogen requirements of the individual. In 
this way the gastric function will not be overtaxed and the stom- 
ach will be spared and enabled more readily to regain its normal 
tone than if it is continuously overloaded with food that it can only 
digest with difficulty or not at all. 

THE USE AND ABUSE OF HYDROCHLORIC ACID. 

The administration of hydrochloric acid as a routine measure Hydrochloric 
in gastric disorders is being abandoned since more careful chem- 
ical examinations of the stomach contents are being universally 
made and treatment is governed accordingly. It is self-evident 
that the administration of hydrochloric acid is, to say the least, 
superfluous, if not directly harmful in cases of dyspepsia in 
which the stomach contents or the vomit show a reaction for free Dangers of 
hydrochloric acid (congo paper or phloroglucin vanillin test). i?pi ine uree °* 
In cases in which free hydrochloric acid is absent and in which 
the total acidity of the stomach contents is greatly reduced, hy- 
drochloric acid may, to advantage, be given, first, as an aid to the 
digestion of albumens in the stomach, i. e., in order to render 
peptic digestion possible; second, as an antizymotic, i. e., in order 
to stop abnormal fermentation in the stomach; third, as a stom- 
achic, i. e., to stimulate the outpouring of gastric juice. 

The administration of hydrochloric acid for the purpose of HC1 to replace 
replacing the deficit of hydrochloric acid in the stomach is a sub- jJci th °* 
stitution therapy. The effect of this treatment is greatly over- stomach 
estimated. The small doses of five or eight drops that are com- 
monly given after eating are practically useless and hydrochloric 
acid, in order to be effective at all, must be given in very much 
larger doses. It has been shown by direct experimentation that Inadequacy of 
one cannot give enough hydrochloric acid with an albuminous ls treatment 
diet to cause the appearance of free hydrochloric acid in the stom- 
ach contents, unless such enormous doses are given that the pa- 
tient would be poisoned. One part of hydrochloric acid saturates 
eighteen parts of albumen, and as a hundred drops of dilute 
hydrochloric acid contain only 0.8 gm. of HC1, this amount would 
only be sufficient to neutralize fifteen grammes of albumen. 

In order to aid the peptic digestion of albumens, fifteen to 
twenty drops of dilute hydrochloric acid in about 100 cc. of wa- 
ter should be given immediately after eating, and the same dose 
repeated every hour thereafter for three or four doses ; or the same 
dose may be given immediately after eating and every fifteen min- 



516 DISEASES OE THE DIGESTIVE APPARATUS 

Disadvantages utes thereafter for three or four doses. The introduction of such 
Hcf 1Vmg mU ° l ar g e quantities of water is, however, not without detriment. Some 
patients react to the administration of so much hydrochloric acid 
by gastric distress and pain, and unless the remedy is taken through 
a glass tube the teeth may be injured; all these disadvantages 
render the administration of hydrochloric acid as a substitute for 
the gastric hydrochloric acid a rather hazardous and by no means 
always an effective procedure. 

Whereas, therefore, the administration of hydrochloric acid 
as a direct substitute for the deficient hydrochloric acid in the 
gastric contents is a procedure of doubtful efficacy, regarded from 
the purely chemical standpoint, we know, clinically, that the ex- 
hibition of much smaller doses than those required according to 
the above reasoning are occasionally useful in relieving dyspeptic 
Effect of HC1 symptoms. This may be due to the fact that hydrochloric acid 
trie HC1 stimulates the flow of gastric juice. This point, however, is still 

uncertain, for the cases in which an increased flow of gastric 
juice seemed to follow the administration of free hydrochloric acid 
are not without ambiguity. It is not impossible that the admin- 
istration of some hydrochloric acid after eating acts as a rest 
cure, so to say, to the hydrochloric acid glands of the 
Action of HC1 stomach by relieving them of some of the labor necessary to man- 
digestion ufacture hydrochloric acid, and hence enables them to more 
readily regain their normal tone. Hydrochloric acid is also known 
to stimulate the pancreatic secretion and therefore it may aid 
intestinal digestion and, provided the motor power of the stom- 
ach is good, promote the vicarious disassimilation of the albumens 
in the bowel. 
HC1 before If it is desired to utilize the stimulating effect of hydrochloric 
acid upon the flow of gastric juice and upon the pancreatic secre- 
tion, the remedy should be given in doses of ten to twenty drops 
diluted with about 100 cc. of water, a quarter to half an hour be- 
fore eating. Administered in this way its full stomachic effect be- 
comes promptly manifest. The administration of hydrochloric acid 
in this manner is by far more rational and generally much more 
effective than the administration of larger doses during the meal or 
immediately afterwards. Hydrochloric acid administered in this 
way also stimulates the appetite. 
HC1 as an in- In some cases it appears moreover to increase peristalsis and to 
septic ac ^ i n a sense, as an intestinal antiseptic ; so that it is particularly 
useful in the treatment of the diarrhea and fermentative intestinal 
dyspepsia that so often complicates chronic gastritis. 

HC1 as an an- Aside from its action as a digestant and as a stomachic, hvdro- 

tizymotic 

chloric acid is also administered for the purpose of holding the 

pullulation of saccharophytes in the stomach in check. Fermenta- 



DISEASES OF THE DIGESTIVE APPAKATUS 517 

tion due to various moulds, fungi and bacteria is particularly ac- 
tive in the stomach in cases in which the hydrochloric acid secre- 
tion is reduced and in which stagnation of stomach contents oc- 
curs. It is very questionable whether administration even of large 
doses of hydrochloric acid can stop fully developed fermentation 
in the stomach; as a prophylactic, however, given before meals, 
the administration of hydrochloric acid is exceedingly useful; for 
by this practice we are imitating Nature's mode of preventing over- 
growth of fermentative micro-organisms in the stomach. Here, 
too, then the administration of small doses of hydrochloric acid on 
an empty stomach is effective, whereas the administration of large 
doses during or after meals is of very little value. 

DRU'GS IN CHRONIC GASTRITIS. 

Alkalies are frequently administered in cases of hypochlor- Alkalies 
hydria or gastric anacidity on the supposition that they act as 
stimulants to the flow of hydrochloric acid, especially if given 
before meals. It has been claimed that a reactive outpouring of 
hydrochloric acid occurs upon their administration which is in- 
tended to neutralize the alkali placed into the stomach. Experi- 
mental and clinical evidence, however, demonstrates this suppo- 
sition to be wrong. It is true that in healthy subjects certain of 
the alkalies given on an empty stomach can cause some increased 
outpouring of gastric juice, but they share this property with any 
other drug that might be poured into an empty stomach and 
that irritates the gastric mucosa; but they do not fulfill this pur- 
pose so well as the bitters or stomachics to be presently discussed. 

The administration of alkalies before meals is, of course, an Alkalies be- 
exceedingly useful procedure in gastric hypersecretion and hyper- meals 1 * 
chlorhydria on account of the antacid action they exercise and the 
same antacid properties render them useful when administered 
after meals, not only in the hyperacidity that is due to an excessive 
outpouring of hydrochloric acid, but also in gastric acidity due to 
the formation of abnormal organic acids by fermentative micro- 
organisms. In the symptomatic treatment of chronic gastric ca- 
tarrh they have a place, therefore, as neutralizers of organic acid 
and also of excessive hydrochloric acid in those rare cases of 
chronic gastric catarrh that are accompanied by hyperchlorhydria. 
Furthermore, alkalies are useful in dissolving the mucus in chronic 
gastric catarrh. Much better, however, than the administra- 
tion of alkalies by swallowing either for the purpose of neu- 
tralizing organic acids or dissolving mucus is their introduc- 
tion into the stomach by means of the stomach tube when lavage 
is performed (see above). As the formation of organic acids 
and stagnation of stomach contents does not occur, however, in 



518 



DISEASES OF THE DIGESTIVE APPARATUS 



Stomachics 
Bitters 



Mode of action 



Gentian 
Quassia 
Condurango 
Mux vomica 
Cinchona 



gastric catarrh if proper lavage is instituted, and as the adminis- 
tration of alkalies after meals would neutralize small amounts 
of hydrochloric acid that are usually formed in chronic gas- 
tric catarrh, their utility as a medicine in this disease 
is very limited. Their employment in hypersecretion and hyper- 
chlorhydria complicating gastric catarrh will be discussed in the 
section on these disorders. 

Medicine belonging to the group of stomachics and simple bit- 
ters are very useful in chronic gastric catarrh. In most cases 
they increase the appetite, stimulate the flow of gastric juice and 
increase the motor power of the stomach. They are especially 
useful in cases of chronic gastritis accompanied by a reduction of 
hydrochloric acid, but they are distinctly contra-indicated in hyper- 
chlorhydria of any kind. Whereas, from a pharmacologic stand- 
point two groups of remedies, viz. : stomachics and bitters, may, 
somewhat artificially, be distinguished, from a practical, i. e., 
clinical standpoint, this differentiation is altogether superfluous. 
As a matter of fact, we know very little of the exact mode of 
action of the stomachics and bitters, and the literature is full 
of contradictory statements in regard to their efficacy. Some of 
the remedies of this group produce hyperemia of the gastric mu- 
cosa, others possibly exercise a directly stimulating effect 
upon the gastric glands. Inasmuch as all these remedies have a 
different composition and origin and are in no way related to one 
another chemically, but as they all have in common both their 
effect upon the appetite and digestion and their bitter taste, it 
seems reasonable to attribute their chief influence to the latter 
property. It is quite probable, especially in the light of Pawlow's 
recent researches, that they act on the gastric digestion and upon 
the appetite through nervous reflexes emanating from the mouth, 
i. e., by their taste, producing, like many other substances with 
pungent odors or strong tastes, a reflex secretion of gas- 
tric juice. Besides, a certain psychic effect resulting from the 
popular prejudice in favor of bitter remedies as efficient stomachics 
cannot be excluded. 

The number of stomachics and bitters is very great, and it is a 
difficult matter to select from them. The most popular are the 
following: Gentian, given as the fluid extract in ten to thirty 
minims (0.7 to 2 cc.) or as the compound tincture of gentian 
in the dose of one-half to four drachms (2 to 16 cc.) ; quassia, 
as the tincture, fifteen to sixty minims (1 to 4 cc.) or the fluid 
extract, five to thirty minims (0.3 to 2 cc.) ; condurango, as the 
fluid extract, fifteen to twenty minims (1 to 1.3 cc.) or the wine 
of condurango, two to four drachms (8 to 16 cc). In place of 
these simple bitters preparations of nux vomica, one to five min- 



DISEASES OF THE DIGESTIVE APPARATUS 



519 



ims (0.06 to 0.3 cc.) of the tincture; cinchona, as the tincture, 
one to four drachms (4 to 15 cc.) or the fluid extract of cinchona 
in one drachm (4 cc.) doses. 

Many drugs of the volatile oil series containing, in addition to 
the aromatic oils some bitter principle, are also used ; for instance, 
in tinctures of cardamom, cinnamon, anis, nutmeg, caraway bit- 
ter almonds and many others in the form of spirits, waters, tinc- 
tures, fluid extracts or infusions, and, besides, certain of the pep- 
pers and mustard. 

A very useful synthetic remedy that, in some instances, exer- 
cises a remarkably stimulating effect upon the appetite, is orexine. 
Orexine itself, if given in large doses, may cause a burning sensa- 
tion along the esophagus and in the stomach, and, in susceptible 
subjects, nausea and vomiting. Basic orexine is the best prepara- 
tion, as it is only slightly irritating to the stomach and, in nearly 
all cases, produces an increased flow of gastric juice, aids diges- 
tion and stimulates the appetite. Basic orexine should be given in 
capsule containing five grains (0.3 gm.) in the middle of the after- 
noon with a full glass of water or milk; or one can begin with a 
smaller dose of two grains (0.1 gm.) on the first day and increase 
it by a grain or two a day until a dose of five or six grains is 
reached. In either case the remedy should be taken only for four 
or five days; within this period good results are usually obtained. 
After the fourth or fifth day the further administration of the 
remedy is generally superfluous, especially as its effect wears off. It 
is often good practice to stop the administration of orexine for a 
week and then to resume the use of the medicine for four or five 
days again. 



Cardamoms 

Cinnamon 

Anis 

Nutmeg 

Caraway 

Bitter almonds 

Peppers 

Mustard 



Orexine 



Basic orexine 



THE USE OF DIGESTIVE FERMENTS. 

The administration of digestive ferments, pepsin, pancreatin, 
ptyalin, as well as of certain vegetable ferments with proteolytic 
or diastatic properties, is very popular. The utility of these prod- 
ucts in dyspeptic disorders, is, however, highly problematic. 

Pepsin is indicated on theoretical grounds where the secretion 
of pepsin by the gastric glands is deficient. This is a very rare 
event; for it will be found that even in those cases in which the 
hydrochloric acid secretion is very low, pepsin, or at least pepsin- 
ogen, is excreted and that the albumen digesting power of the 
gastric juice is small, not on account of the pepsin deficit, but for 
lack of hydrochloric acid. In an overwhelming majority of these 
cases the addition of hydrochloric acid to the gastric juice will 
promptly restore its proteolytic power, so that stimulation of the 
flow of hydrochloric acid or the administration of large quantities 
(see above) of hydrochloric acid is all that is required. The ad- 



Digestive 
ments 



Pepsin 



fer- 



520 



DISEASES OF THE DIGESTIVE APPARATUS 



Preparations 
of pepsin 



Papain 

Bromelin 

Cradin 



Pancreatin 



ministration of pepsin, itself, is indicated, therefore, only in those 
cases in which the gastric contents, rendered acid with hydro- 
chloric acid, fails to digest proteids. To administer pepsin when 
free hydrochloric acid is present in the stomach contents is alto- 
gether futile, for it has been shown that, when free hydrochloric 
acid is present, pepsin is always secreted in abundant quantities. In 
rare cases of achylia gastrica, in nervous anacidity and apepsia, 
in atrophy of the gastric glands and occasionally in gastric car- 
cinoma pepsin may be of some value. In certain advanced cases of 
chronic gastric catarrh, in which the pepsin secretion is reduced 
on account of functional weakness of the peptic glands, the admin- 
istration of pepsin in combination with hydrochloric acid may also 
aid to some extent both by actually furnishing pepsin and by re- 
lieving the peptic glands of the labor of secreting pepsin, hence 
sparing them and enabling them better to regain their normal 
function. 

The popular wines and essences of pepsin are always weak and 
frequently possess no proteolytic power whatsoever; in fact, the 
alcohol they contain somewhat impairs the action of the pepsin. 
These remedies, besides, if given in large quantities, may injure 
the stomach. The official pepsin of the U. S. P., made from the 
glandular layer of pig's stomach, should be capable of digesting 
not less than three thousand times its weight of coagulated egg 
albumen. It is dispensed in powder form or as fine scales, either in 
capsules containing five to ten grains (0.3 to 0.6 gm.), or in a 
0.2 per cent, hydrochloric acid solution, immediately after or dur- 
ing meals. 

Papain (papayotin or papoid), a product made from carica 
papaya, and bromelin made from pineapple and cradin from ficus 
carica, all possess considerable proteolytic powers. 

The best of this group is papain, which does not digest proteids 
as energetically nor as rapidly as pepsin, but possesses this advan- 
tage over pepsin, that it digests albumen not only in an acid but 
also in a neutral or alkaline medium, so that it continues its effect 
after it has left the stomach. 

Pancreatin, a mixture of the enzymes of the pancreas, is ad- 
ministered in powder or capsule in the dose of two to five grains 
(0.1 to 0.3 gm.) only if the secretion of hydrochloric acid is re- 
duced, or if hydrochloric acid is altogether absent from the stom- 
ach ; for it does not act in an acid medium and is rapidly destroyed 
by the action of hydrochloric acid in the stomach. If some hy- 
drochloric acid is present in the gastric juice, then this must be 
neutralized by administering sufficient soda with pancreatin. In 
this way pancreatic digestion is, so to say, transferred to the stom- 
ach. Inasmuch as the pancreatic secretion is rarely impaired in 



DISEASES OF THE DIGESTIVE APPARATUS 521 

gastric disorders, it is much more rational to promote rapid pro- 
pulsion of the stomach contents into the bowel, for there the food 
is at once exposed to the action of the normal pancreatic ferments. 
In cases of insufficiency of the pancreatic secretion in the bowel 
(a condition that it is almost impossible to diagnose), pancreatin 
might be given in gelatin capsules that withstand the hydrochloric 
acid of the stomach; or pancreon, a tannic acid precipitate of Pancreon 
pancreas, may be administered, for this remedy resists the action 
of the gastric juice for four or five hours. It may be given in 
doses of five grains (0.3 gm.) in watery solution, during meals, 
if hydrochloric acid is absent, half an hour before meals if hydro- 
chloric acid is present in the stomach. It will be seen, therefore, 
that in chronic gastric catarrh the use of pancreas preparations is 
very limited. Pancreas preparations as well as amylolytic, i. e., Amylolytic 
starch digesting ferments as, for instance, ptyalin made ferments 
from salivary glands, malt diatase (malt extract, maltzyme, . 
maltin, etc.) takadiastase (from aspergillus oryza) are Taka-diastase 
indicated only in gastric hyperacidity in combination with 
alkalies; hence they are practically never used in chronic gastric 
catarrh. 

With the introduction of systematic lavage, the judicious use Treatment of 
of hydrochloric acid and stomachics, and the proper administra- s P ecial symp- 
tion of a carefully selected diet to fit the state of the gastric 
function as determined by analysis of the stomach contents, the 
use of medicines for the treatment of special symptoms like nau- 
sea, vomiting, gastric pain, belching, meteorism, diarrhea and 
constipation has become practically needless. If the decomposing 
and fermenting contents and the offending mucus are removed 
at frequent intervals by lavage with alkaline waters, the forma- 
tion of gases and of irritating acids in the stomach and their 
propulsion into the bowel is to a large extent prevented. Hydro- Nausea 
chloric acid, judiciously administered, also in a measure im- Vomiting 
pedes the formation of toxic bodies and aids in the proper dis- Pam 
assimilation of the food, hence increases the appetite and the gen- 
eral nutrition. No occasion, therefore, under this treatment is Constipation 
given for the development of nausea, vomiting, belching, meteor- Diarrhea 
ism or diarrhea. The constipation, if persistent, should be com- 
bated chiefly by the ingestion of abundant fresh fruits and vege- 
tables, by laxative mineral waters, occasionally by a little rhu- 
barb and by enemata, but not by strong vegetable or mineral purga- 
tives, as the latter may seriously injure the irritated and inflamed 
gastric mucosa and hence impede the healing process. Severe and 
persistent gastric pain can, as a rule, be effectually stopped by the 
application of Priesnitz compresses or of hot water bags to the 
epigastrium, so that the use of narcotics will rarely become neces- 



522 



DISEASES OF THE DIGESTIVE APPARATUS 



sary. Hyperchlorhydria complicating chronic gastritis and pro- 
ducing pain (a rare event) should be combated according to the 
principles discussed in full in another section. 



GASTRIC ULCER. 



General indi- 
cations 



Causal and 

prophylactic 

treatment 



Factors that 
impede healing 
and favor ex- 
tension 



The healing of an ulcer of the stomach is self evidently accel- 
erated if the stomach walls are kept in a quiet, contracted condi- 
tion and if the surface of the ulcer is protected, so far as that is 
possible, from mechanical, thermic and chemical irritation. An 
ulcer of the stomach differs in this respect in no way from an 
ulcer located in any other part of the body; for anywhere healing 
is promoted by quiet of the adjacent parts, the avoidance of 
stretching and the protection of the surfaces of the ulcer from 
extraneous irritants. 

In gastric ulcer certain difficulties inherent in the character 
of the ulcer, the peculiar anatomy of the stomach and the nature 
of its functions, are encountered that render the carrying out 
of this plan very difficult. Complete rest of the stomach wall 
and avoidance of distention, as well as protection of the ulcer sur- 
faces, can only be procured by withholding all food for a time, 
and later by carefully administering liquid, soft, bland foods of 
moderate temperature; at the same time, the acidity of the stom- 
ach contents, which is usually increased in ulcer, must be reduced 
by appropriate feeding and medication; and the healing of the 
ulcer, so far as that is possible, stimulated by direct medication. 
Above all things, during this time every effort must be advanced 
to maintain the patient's general nutrition, as otherwise the organ- 
ism becomes unfit to put forward its best efforts towards pro- 
moting regeneration and healing in the affected area. 

Inasmuch as ulcer of the stomach is presumably always pro- 
duced by some mechanical agency, trauma, thrombosis, etc., affect- 
ing either a healthy subject or an individual suffering from anemia, 
chlorosis or circulatory disorders in the stomach wall, causal treat- 
ment is manifestly impossible. This is due to the fact that 
the injury that directly produces the ulcer cannot be anticipated 
nor forestalled, so that prophylaxis in the broader sense is out of 
the question. 

We know, however, that the failure of gastric ulcer to heal as 
promptly as ulcers in other parts of the body, and its tendency 
to extend, must, in large part, be attributed to the hyper- 
chlorhydria that usually accompanies gastric ulcer; we know 
further that anemia and chlorosis not only predispose to gastric 
ulcer, but impede its healing ; hence in the presence of gastric ulcer 



DISEASES OF THE DIGESTIVE APPARATUS 



523 



the treatment should always be directed towards correcting 
gastric hyperacidity and any anemia or chlorosis that may exist, 
according to methods that are described in full in appropriate sec- 
tions. 

Complete abstinence from food for a period of time, fluctuat- 
ing from a few days to several weeks according to the peculiar 
exigencies of the case, is always good practice. In most cases it 
is safe to resume the administration of some food after the fifth 
day, for equally good results are generally obtained from this 
course, provided the feeding is carefully instituted according to 
the principles to be presently discussed, as from total abstinence 
from food for a period of several weeks. The latter plan of treat- 
ment, which, is now very popular, is, therefore, as a rule, unneces- 
sarily severe, moreover very difficult to carry out on account of 
the unwillingness on the part of the patient to undergo such a 
trying ordeal; above all, there is much difficulty in most cases to 
maintain adequate nutrition by rectal feeding (see below) alone. 
When one considers, furthermore, that rectal feeding undoubted- 
ly stimulates gastric secretion to some extent (one of the factors 
one is precisely trying to avoid by withholding food by mouth), 
this plan of treatment seems particularly useless in most cases. 

In patients suffering from severe gastric pain and vomiting, and 
notably from repeated hemorrhage from the stomach, whenever 
food is administered, the total abstinence plan with rectal feeding 
may, however, have to be reluctantly instituted for long periods 
of time, i. e., until all these symptoms disappear, or until, espe- 
cially in cases of persistent hemorrhage, the proper time arrives 
for surgical intervention (see below). 

A patient with, gastric ulcer should always be kept in bed for 
a period of at least two weeks, or preferably longer, particularly 
if there is a tendency to hemorrhage or if symptoms of perito- 
neal irritation or inflammation are present. In the latter event 
the application of an ice bag or of a Leiter coil to the epigastric 
region is a useful measure, otherwise Priesnitz compresses or hot 
poultices, or a hot water bag for several hours each day, are more 
grateful to the patient. While in bed all violent movements should 
be carefully avoided and the patient should not be allowed to get 
out of bed even for the purpose of emptying the bladder or rectum. 
During the third and fourth weeks of treatment the patient may 
be permitted to sit up for a little while each day, and later take 
short walks about the room, and still later out-of-doors. For 
several weeks after the ulcer symptoms have disappeared, it 
is always a good plan to instruct the patient to lie down for an 
hour after each meal. 



Complete absti- 
nence from 
food 



Feeding after 
fifth day 



Disadvantages 
of rectal feed- 
ing 



Indications for 
rectal feeding 



Rest in bed 



Heat and cold 
to epigastrium 



Exercise during 
convalescence 



524 



DISEASES OE THE DIGESTIVE APPARATUS 



Thirst 



Rectal irriga- 
tion 



Rectal feeding 



Nutritive ene- 
mata 



Addition of 
salt 



During the period of total abstinence from food, the distress- 
ing sensation of thirst that so many complain of should be coun- 
teracted by frequently washing the mouth with cold water and al- 
lowing the patient to suck ice pills without swallowing the water. 
The demands of the organism for water should be fulfilled by 
rectal irrigation; i. e., from 250 to 500 cc. of normal salt solu- 
tion containing eight to ten grammes of sodium chloride to 
the litre of water should be injected, lukewarm, into the rectum, 
several times a day. If it is desired to slightly stimulate the pa- 
tient, a little brandy or white wine may be added to this water 
enema, or a little bouillon may be used on account of its stimu- 
lating effect. 

In feeding a patient by the rectal route one should proceed 
as follows : Prior to the injection of the nutritive enema, the low- 
er bowel should be carefully washed out with warm, soapy wa- 
ter. An hour later, or sooner if all the wash water has been 
expelled, the nutritive clysma should be injected by means of 
a soft rubber catheter and an irrigating bag elevated about three 
feet above the patient. The tube should be introduced as far as 
possible into the colon. The patient should lie on the left side 
with the right leg drawn up, and the hips elevated by a pillow or 
two. After the clysma has been injected the patient should remain 
perfectly quiet, preferably in the same position, for about an hour. 
The temperature of the enema should approximate that of 
the body. If the patient is unable to hold the enema, or if 
the clysma produces too much irritation, an event that is espe- 
cially apt to occur if peptones or albumoses are used, then ten 
to twenty drops of the tincture of opium may be added to the 
enema. The total amount of the clysma should not exceed 250 cc. 
Rectal feeding may be instituted in this way two or three times a 
day. 

Many nutritive enemata of different composition have been 
described, for nearly every author who has written on this sub- 
ject has devised some new mixture. One of the best and simplest 
forms of nutritive enemata that answers all purposes if rectal 
feeding is to be instituted for a -short time only, and this is 
usually the case, is the following : 

250 cc. milk. 

2 yolks of* egg. 

2 tablespoonfuls of claret. 

A pinch of salt. 

The addition of salt to nutritive enemata is very important, 
for it has been shown conclusively that the addition of sodium 
chloride greatly aids in the absorption of the nutrient bodies con- 



DISEASES OF THE DIGESTIVE APPARATUS 



525 



tained in the enema. The action of the salt is probably attribu- 
table to its power to stimulate antiperistalsis and hence to cause 
food injected into the rectum or colon to be carried into the small 
intestine, where absorption is much more active than in the lower 
bowel. 

Peptones and albumoses, i. e.,, predigested albumens, aside 
from irritating the bowel in many cases are not absorbed more 
rapidly than native albumen itself, hence their addition to nu- 
tritive enemata, which is commonly recommended, is usually su- 
perfluous. Nevertheless, the following clysma, recommended by 
Singer, is very popular and occasionally serves a useful pur- 
pose: 

125 cc. of milk. 

125 cc. of claret. 

2 yolks of eggs. 

A little salt. 

A desertspoonful of Witte's peptone. 



Peptones and 
albumoses 



Sugars 



The different sugars are rapidly absorbed from the intestine, 
but, as they easily undergo decomposition and lead to fermenta- 
tive gas formation and distention of the bowel, their use cannot 
be particularly recommended. Of the various sugars that can be 
used dextrose is the most valuable, but its extensive employment 
is rendered impracticable by its cost. A simple nutritive enema 
recommended by Ewald and containing dextrose is made as fol- 
lows : 

Two or three eggs are mixed with, a tablespoonful of cold Ewald's nutri- 
water. A little flour is boiled in half a cup of a twenty per cent. tlvi 
dextrose solution and allowed to cool. To this solution a wine 
glass full of claret is added, the egg solution stirred in and the 
mixture filled up with water to 250 cc. 

When using eggs for a nutrient enema the bowels should be Egg enema 
thoroughly cleansed about an hour or two later, as otherwise de- 
composition of the egg albumen in the rectum may occur and 
toxic putrefactive bodies that are highly irritating be formed. 

After four or five days of total abstinence from food with Feeding after 
rectal feeding, milk should be, carefully administered by mouth 
at first in small doses of two or three tablespoonfuls, boiled and 
cold. After a hemorrhage it is best to give still smaller quantities 
of iced milk every two or three hours, or every hour. If the 
milk causes vomiting, and especially if large curds form, an event 
that is not uncommon if raw milk is administered but is not so Milk 
apt to happen if the milk is boiled, the addition of a little lime 
water or of soda, or the administration of tablespoonful doses of 
ice cold milk at frequent intervals may stop these symptoms and 



526 



DISEASES OF THE DIGESTIVE APPARATUS 



Exclusive milk 
feeding not 
practical 



Milk powder 

Condensed 
milk 

Buttermilk 

kephyr, 

kumyss 



Gruels 



Meat jelly 



Albumen 

water 

Egg bouillon 

Dextrose so- 
lution 



Diet during 
second ten days 



Diet during 
third and 
fourth week 



Diet during 
convalescence 



enable the patient to take the milk by month. The latter mode 
of administration is also efficacious in subjects who manifest a 
severe dislike to milk. 

Exclusive milk feeding is never a feasible plan, for, in order to 
adequately nourish the patient with milk alone far too much 
liquid must be introduced, and if the patient is to be fed with 
small quantities of milk at a time the administration of milk 
would have to be practically continuous throughout the day; for 
this reason the addition of milk powder, 100 grammes to the litre 
of milk, or of one to two teaspoonfuls of condensed milk to the 
litre of milk, may be practised in order to increase the nutritive 
value of the milk. In order to afford variety, buttermilk, kephyr 
or kumyss may be tried, but it must be remembered that all these 
milk products contain less fat and sugar than milk, and 
are hence less nourishing. Within the first ten days after total 
abstinence from food a little tapioca, rice, wheat, barley or oat- 
meal flour may be boiled in milk and these gruels given in place 
of milk alone. 

A very useful, nutritious and non-irritating addition to the 
bill of fare during this period is meat jelly prepared, according to 
Fleiner, by boiling chicken or beef with a calf s foot for several 
hours with the addition of a little salt. The soup, cooked in this 
way, is cleared by stirring in an egg and heating to a boil, the 
fluid is strained off and on cooling coagulates to a jelly. Of this 
meat jelly a dessertspoonful may be given every few hours. Dur- 
ing this period, too, albumen water, made by dissolving white of 
egg in salt water, or an egg stirred up in a little bouillon, may 
also be allowed. Twenty per cent, solutions of dextrose in milk 
or water are also permissible. Such a sugar solution is quite 
nutritious and also possesses some antacid properties that are 
beneficial. 

On this simple diet, usually reinforced by one or two rectal 
feedings a day, the patient remains for the- first ten days. Dur- 
ing the second ten days of the ulcer cure the amount of the gruels 
is gradually increased and some of the soft and digestible meats, 
like squab, chicken, calves' brains, scraped raw meat, also a little 
mashed potato, boiled rice, noodles or macaroni, tapioca, sago, a 
little boiled cauliflower or zwieback soaked in milk may be al- 
lowed. 

Later still, i. e., during the third and fourth week, a little 
roast beef, beef steak, poultry, some boiled fish, vegetable purees 
made of green peas, beans, carrots, a little chopped spinach, as- 
paragus tips, some scrambled eggs or an omelet, may be permitted. 

As a more liberal diet is resumed, particular care should be 
exercised to exclude all mechanically irritating foods, as certain 



DISEASES OF THE DIGESTIVE APPARATUS 



527 



Carlsbad 
salts 



cereals and vegetables containing husks, stems, pips, skins or stalks, 
as well as berries, on account of their seeds, hard bread crusts, 
etc. Very hot or very cold foods and drinks, spices, condiments, 
strong alcoholic beverages and coffee are best avoided. It is al- 
ways safer to administer small meals at frequent intervals than 
two or three large meals a day, even for weeks after the ulcer has 
healed. 

A very useful measure, adopted almost as a routine in Euro- 
pean clinics, is the administration of one or two teaspoonfuls of 
Carlsbad salts dissolved in 250 cc. of water every morning on an 
empty stomach. The chief ingredients of Carlsbad salts are 
sodium chloride, sodium carbonate and sodium sulphate, and it 
is difficult to explain the beneficial action derived from the use 
of this mixture. It is probable that it acts in several ways, by 
dissolving the mucus, by neutralizing the excessive acidity and as 
a laxative. 

The reduction of hyperacidity, which is a very important ele- 
ment in the treatment of gastric ulcer, will be discussed in full in 
a separate section. In ulcer cases living on a diet consisting large- 
ly of milk and eggs, the hydrochloric acid of the gastric juice is 
partially neutralized by the latter, for the albumen they contain 
possess slight antacid properties. The addition of an alkali, either Antacids 
a tablespoonful of lime water to each glass of milk, or soda or 
magnesia, enforces this effect. 

A very popular method of treating hyperacidity in gastric ulcer 
is by means of the following mixture: 



Reduction of 
hyperacidity 



3 



Sodium carbonate, 
Burnt magnesia, of each, 
Sugar of milk, 



100 parts 
150 parts 



This mixture is procured in bulk and the patient adds half 
a teaspoonful to each glass of milk. Carlsbad water or Carlsbad 
salts may also be used as an antacid addition to the milk, or 
Carlsbad salts may be taken immediately after each meal. If there 
is hyperacidity occurring not only after eating, but also hyper- 
secretion, so that acid gastric juice is present when the stomach 
is empty, then it may become necessary to administer alkalies be- 
tween meals. In very excessive degrees of hyperacidity that cannot 
be readily controlled by the administration of alkalies, the use of 
atropine or belladonna may be required. The former should be 
given hypodermically in the dose of one hundredth of a grain (0.6 
mg.) once or twice a day, the latter as the extract of belladonna by 
mouth in capsule with an alkaline water in the dose of a quarter 
grain (0.01 gm.) three times a day. 



Carlsbad 
Salts 



Atropine 
Belladonn; 



528 



DISEASES OE THE DIGESTIVE APPARATUS 



Silver nitrate 



Dose and ad- 
ministration 



Chloroform 
water 



Indifferent 
powders 



Another remedy used as an antacid and credited, moreover, 
with healing properties in gastric nicer, is silver nitrate. This 
drng seems to be of particular value if much pain is complained 
of when the stomach is empty and also in gastric hyperesthesia 
with abnormal sensitiveness to the introduction of food. As silver 
nitrate neutralizes hydrochloric acid by precipitating the latter 
in the form of silver chloride, it is said to possess some antacid 
power, but, considering the small amounts of the drug that can be 
introduced, this effect is insignificant and the good symptomatic 
results obtained from the use of silver nitrate in gastric ulcer 
must be attributed in large part to some influence exercised by 
the drug upon the sensory apparatus of the stomach that is not 
altogether understood. 

Silver nitrate is best given in a solution of the strength of 
one to one thousand in tablespoonful doses, three or four times a 
day on an empty stomach. If this concentration is well borne the 
strength of the solution may be gradually increased to one and 
one-half to one thousand, then to two to one thousand, and the 
patient kept on tablespoonful doses of the stronger solutions three 
times a day throughout the course of the disease, i. e., for a period 
of from four to six weeks. Slight nausea and diarrhea that oc- 
casionally make their appearance in the beginning of this treat- 
ment are generally negligible, as these symptoms usually disappear 
spontaneously within a few days, and without special interfer- 
ence. The bad taste that patients taking silver nitrate solutions 
sometimes complain of can best be counteracted by peppermint or 
eucalyptus lozenges. 

As an anesthetic choloform water can also be used in gastric 
ulcer, either alone, in the dose of a tablespoonful every two 
or three hours, or in combination with bismuth in the following 
formula : 

Chloroform, 1 gm. 

Distilled water, 150 gm. 

Bismuth subnitrate, 3 gm. 

One to two teaspoonfuls every hour (Stepp). 

A number of indifferent powders like bismuth subnitrate or 
carbonate, orthoform, talcum, chalk, etc., may be used to advan- 
tage in gastric ulcer, more on account of their mechanical effect 
than because of any medicinal properties they possess. These sub- 
stances form a thin coating over the ulcer surface, thus protecting 
it from the irritating action of the food and the gastric juice ; at 
the same time they act as hemostatics by forming a powder cake 
over the bleeding area ; they also generally relieve the pain. 



DISEASES OF THE DIGESTIVE APPARATUS 529 

Bismuth subnitrate should be given in large doses of two or Bismuth sub- 
three drachms (8 to 12 gm.) suspended in about 100 cc. of carbonate 
water, on an empty stomach. If the ulcer can be localized, the pa- 
tient, after swallowing this mixture, should occupy such a posi- 
tion that the ulcer is in the most dependent part of the stom- 
ach ; i. e., if the ulcer is situated at the lesser curvature or on the 
posterior wall of the stomach, the patient should occupy the dor- 
sal position with his hips elevated; if at the pyloric part, he 
should lie on the right side; if on the anterior wall, he should lie 
on his face or occupy the knee-chest position. The appropriate 
posture should be maintained for about fifteen minutes to one 
hour. If the exact localization of the ulcer is impossible, and this 
will be the rule, the patient should lie for fifteen minutes succes- 
sively on his back, his stomach, his left and his right side; in 
other words, he should perform complete rotation of the body 
within the space of an hour. 

It is rarely necessary to introduce the remedy through a stom- Introduction of 
ach tube; this procedure, in fact, is never without danger, espe- tu k mut Y 
cially in recent ulcer, in ulcer near the cardia or in ulcer with a 
tendency to hemorrhages. If it is decided, however, to give the 
bismuth by tube, the stomach should first be thoroughly washed 
out with slightly alkaline, lukewarm water and after the last 
of the wash water, which should be perfectly clear, has been 
pumped or siphoned out, two or three drachms (8 to 12 gm.) of 
bismuth subnitrate or carbonate, suspended in a 100 cc. of luke- 
warm water should be poured into the funnel and washed down 
with a small quantity of water. The stomach tube should be 
left in place for five to ten minutes, in order to give the bismuth 
time to settle, then the water may be siphoned off and the tube 
withdrawn; or the tube may be introduced a second time very 
carefully and the water drawn off in this way. The former pro- 
cedure, however, is by far the more practical one of the two. Best 
of all and least disagreeable to the patient, is swallowing the bis- 
muth mixture without the aid of the stomach tube. 

The bismuth treatment should be given from the beginning, 
at first every day, then every second day and later every third 
day. The effects from this therapy are generally very favorable 
and untoward symptoms on the part of the stomach, or poisoning 
from the absorption of bismuth (stomatitis, etc.), even when the 
drug is given in much larger doses than those indicated above, are 
never witnessed. 

Orthoform, as such, or in the form of its muriate, is as useful Orthoform 
as bismuth subnitrate or carbonate; it should be given in doses of 
sixty to ninety grains (4 to 6 gm.) suspended in a 100 cc. of water 
in the same way as bismuth. 



530 



DISEASES OF THE DIGESTIVE APPARATUS 



Talcum-Chalk 
Magnesia mix- 
ture 



Olive oil 



Narcotics 



Hot and cold 
applications 



Bismuth salts and orthoform, especially if they are to be used 
in such large quantities, are quite expensive, and in private prac- 
tice the following mixture, recommended by Pariser, may be ad- 
vantageously used instead: 



v 



Talcum, 
Chalk, 
Magnesia usta, 



60 parts 
60 parts 
15 parts 



Of this preparation five drachms are mixed with water and 
administered in the same way as bismuth. The slight antacid 
and laxative properties of the magnesia, and the fact that the 
ingredients of this mixture do not blacken the stools, and hence 
do not conceal small hemorrhages like bismuth, render this mode of 
treatment quite useful. 

Olive oil, too, may be used for its mechanical effect, especially 
in cases of gastric ulcer with p}doric spasm due to intragastric 
irritation, with resulting dilatation of the stomach, stagnation of 
the stomach contents, and, consequently, irritation of the ulcer 
surface. Fifty cubic centimeters of olive oil may be introduced 
three times a day, or a hundred and fifty cubic centimeters taken 
on an empty stomach in the morning. The oil may either be swal- 
lowed or administered through the stomach tube. 

If the rest treatment, described above, the careful regulation 
of the diet after a period of total abstinence from food, antacid 
medication with alkalies or Carlsbad water and atropine, the 
silver nitrate, or the bismuth or orthoform treatment are insti- 
tuted, other measures intended to relieve special symptoms, nota- 
bly pain and vomiting, rarely become necessary. 

Narcotics should be used very sparingly and only in severe 
cardialgia and gastric pain that does not yield to hot applica- 
tions to the epigastrium, antacid medication and the proper diet 
or total abstinence. The fact must never be forgotten that opium 
and morphine, aside from causing constipation, which is detri- 
mental, increase gastric secretion, and hence favor precisely the 
outpouring of hydrochloric acid which is in most instances pro- 
ducing the pain in gastric ulcer. Narcotics, therefore, while they 
deaden the sensibility of the gastric nerves, favor the cause that 
irritates them. 

In most instances one must experiment with the use of hot or 
cold applications, some patients experiencing greater relief from 
the application of heat in the form of a hot water bag, poultices 
or the thermophore (see index), others being relieved by cold ap- 
plied in the form of the ice bag, the Leiter coil or Priesnitz com- 
presses. 



DISEASES OF THE DIGESTIVE APPARATUS 531 

Hematemesis always calls for active treatment. Broadly speak- Hematemesis 
ing a recent hemorrhage or a tendency to recurrent hemorrhages 
precludes the application of heat to the epigastrium ; here cold ap- 
plied to this region is always safer. Total abstinence from solid 
food should be insisted upon until all traces of blood, as determined 
by daily chemical tests, disappear from the stools. During this 
time the nutrition of the patient should be maintained chiefly by 
rectal feeding. The patient should remain completely at rest in 
bed. Some patients do very well if they swallow teaspoonful doses 
of ice cold water at frequent intervals, and profuse gastric hem- 
orrhage can frequently be stopped instantaneously by lavage of 
the stomach with ice water. The best method of procedure is the 
following : — 

The patient receives a small injection of morphine. The 
pharynx is thoroughly cocainized in order to prevent gagging and 
vomiting by reflex irritation when the tube is passed. The tube is 
then carefully inserted just beyond the cardia, but not into the 
stomach, and great care is taken that the stomach wall is not 
touched by the end of the tube. Small quantities of ice water are 
introduced at first and the clots of blood that form pumped out 
with the ordinary suction pump, then gradually more water is 
allowed to flow in and thorough lavage of the stomach with the 
ice water is carried out until the wash waters come out clear. 

In view of the fact that in gastric hemorrhages a good deal of 
blood enters the intestine and is apt to produce irritative symptoms 
lower down, it is well to give a mild laxative as soon as possible 
after the hemorrhage is stopped. If collapse phenomena make 
their appearance an injection of camphor dissolved in ether in the 
proportion of 1 to 6 is always useful. At the same time the ex- 
tremities and the abdomen should be covered with hot compresses. 
If the hemorrhage has been very severe, and if the pulse is small 
and symptoms of cerebral anemia put in their appearance, then 
normal salt solution should be administered by hypodermoclysis. 

If possible one should get along without the use of hemostatic Hemostatic 
remedies, and an opportunity for spontaneous cessation of the hem- dru £ s 
orrhage should be given, i. e., an expectant plan, as far as hemo- 
static drugs are concerned, should be followed for twenty- 
four hours, and the patient, during this time, treated by rest, 
cold applications and abstinence from food. If it becomes neces- Adrenalin 
sary to employ a hemostatic, the best remedy of all is probably c londe 
adrenalin chloride, administered in the dose of ten to twenty 
drops of a one to one thousand solution, repeated at intervals of 
half an hour to an hour until the bleeding stops. At the same Opium 
time excessive vomiting should be controlled by the use of opium Morphine 



532 



DISEASES OF THE DIGESTIVE APPARATUS 



Ergotine 



Hydrastis 



Lead acetate 

Bismuth 

Gelatin 



Ferric chloride 
gelatine 



After 
ment 



treat- 



or morphine given hypodermically or by suppository. Subcutane- 
ously, ergotine may be given in the following injection: 



s 



Ergotine, 

Glycerine, 

Water. 



2.5 gm. 
5.0 cc. 
5.0 cc. 
(Eiegel) 



Other remedies that are occasionally useful are the fluid ex- 
tract of hydrastis, given in fifteen to sixty minim (1 to 4 cc.) 
doses, by mouth, or hydrastinine hydrochloride, in the dose of 
one-half to two grains (0.03 to 0.1 gm.) by mouth or hypodermical- 
ly. Lead acetate, in the dose of one grain (0.06 gm.) every two 
hours, or large doses of bismuth, may also prove useful. 

Gelatin sometimes stops hemorrhage; it is conveniently admin- 
istered in the following combination: 



i} 



Gelatin, 

Sodium chloride, 
Water, 



15.0 gm. 
1.2 gm. 

200.00 cc. 



Of this mixture 100 cc. are to be given at once and the bal- 
ance within two or three hours. The use of gelatin must be con- 
sidered an extreme measure that will rarely have to be resorted to ; 
in very profuse hemorrhages, however, it occasionally proves ef- 
ficacious as an emergency measure. 

A very useful remedy for controlling the hemorrhages, espe- 
cially oozing, in chronic gastric ulcer is ferric chloride gelatine. 
This remedy is prepared as follows : — 

100 g. of gelatine are dissolved in a mixture of 100 g. of 
glycerine and water. When a complete solution of the gelatine has 
been brought about, 50 g. of ferric chloride are added to the solu- 
tion. This leads to the formation of coagulates in the mixture and 
the precipitation of a sediment that has to be thoroughly stirred in- 
to the mass until the whole mixture assumes a homogeneous con- 
sistency. The gelatinous mass is then poured out on plates and, 
after it has dried, cut into small pieces half an inch square. These 
platelets of ferric chloride gelatine can be kept almost indefinitely 
in a tightly stoppered bottle. Two or three of these tablets should 
be administered daily two or three hours after meals. 

The after treatment of hemorrhage from gastric ulcer with 
loss of much blood is the same as that described at length in the 
Sections on Hemoptysis and Secondary Anemia. During the hem- 
orrhage and for some days afterwards, the bowels should be kept 
locked by the use of opium suppositories. After the bleeding has 



DISEASES OF THE DIGESTIVE APPARATUS 



533 



stopped, soft evacuations of the bowel contents should be promoted 
by the use of frequent enemata of soapsuds and water, glycerine, or 
oil, in order to avoid straining efforts at stool. 

Ulcers of the stomach that persist or show a tendency to re- 
currence despite the adoption of all the measures outlined above, 
and in which there is much vomiting and pain, or occasionally a 
slight hemorrhage, with resulting mal-nutrition of the patient, 
may call for surgical intervention. Simple, uncomplicated ulcers, 
however, rarely fail to yield to proper medical treatment carried 
out for a sufficiently long time, so that surgery has its chief field 
of usefulness in the treatment of the sequelae and complications of 
gastric ulcer rather than in the treatment of the ulcer itself. 

Repeated, severe hemorrhage may call for a laparotomy, liga- 
tion of the bleeding arteries or excision of the ulcer area. A sin- 
gle severe hemorrhage rarely calls for surgical intervention, as 
statistics show that cases recover from such a hemorrhage with- 
out an operation as well as with an operation; in fact, the mortal- 
ity is slightly higher if a laparotomy is performed in such cases 
than if it is not performed. 

Perforation of an ulcer with invasion of the peritoneum by 
stomach contents; cicatricial contractors about the pylorus or 
cardia causing stenosis; scar tissue forming in other regions of 
the stomach, causing hour-glass contraction or diverticulum forma- 
tion; perigastric adhesions producing dangerous traction or pres- 
sure symptoms on adjacent organs; perigastric abscess, are all 
sequelae and complications of gastric ulcer that, being mechanical 
in character, call for mechanical, i. e., surgical, relief. 

Whether the ulcer is to be excised (and it is well to remem- 
ber that recent ulcers are not always easy to find, and that ulcers 
may be multiple and hence cannot all be excised) or whether a 
gastro-enterostomy is to be performed must depend upon the pe- 
culiarities discovered when the abdomen is opened. It is, as a rule, 
impossible to predict before the laparotomy just what operation 
shall be made. A discussion of the different operative procedures 
that can be adopted lies without the frame of this book. 



Indications for 
surgical treat- 
ment 



Repeated 
orrhages 



hem- 



Surgical treat- 
ment of per- 
foration, adhe- 
sions and other 
sequelae of 
ulcer 



Excision of 
ulcer or gastro- 
enterostomy 



CARCINOMA OF THE STOMACH. 



cure 



The main duty of the internist in the treatment of gastric Surgery the 
carcinoma is to make the diagnosis as early as possible and then only m eans of 
to order surgical intervention. In the case of this disease sur- 
gery is not a last resort, as in so many other disorders, to be tried 
only after the skill of the internist has been exhausted, but a first 
resort to be adopted as soon as the diagnosis is positively made, and 



534 



DISEASES OF THE DIGESTIVE APPARATUS 



Resection of 
pylorus 



Gastroenter- 
ostomy 



Gastrostomy 



the only resort that can bring about a cure of this affliction. It 
is by all means a safe and conservative plan, and one that 
would save many lives if adopted more frequently, to 
perform an exploratory laparotomy in every case of organic sten- 
osis of the pylorus; for no material harm is done in the hands of 
a skillful surgeon if the stricture after laparotomy should be 
found to be due to the presence of benign tissue; while if it 
should be found to be due to carcinomatous tissue, early resec- 
tion may be life-saving. It is unfortunate, however, that carcinoma 
producing stenosis symptoms about the pylorus is usually already 
far advanced. 

Eesection of the cancer in most cases, therefore, is merely a 
palliative measure capable, often, of prolonging the patients' ex- 
istence, but rarely of curing them. At best even complete resec- 
tion of a gastric carcinoma leaves the patient with a stomach whose 
secretory and motor functions, owing to the atrophy of the gastric 
mucosa that almost invariably accompanies gastric carcinoma, re- 
main permanently impaired. 

Eesection of the carcinoma is the operation of choice if the 
tumor is located in the pyloric region, if it is freely movable, i. e., 
not adherent to adjacent parts, if no metastases are present and if 
the general condition of the patient is good. These indications, 
one must confess, are more or less theoretically constructed, espe- 
cially in regard to the absence of metastases, for it is self-evident 
that small metastatic growths in the liver or the mesentery may 
very well escape detection. 

If metastases are found, if the tumor is adherent or if it 
cannot be completely resected, if serious symptoms of stenosis about 
the pylorus with stagnation of gastric contents are present, then 
gastroenterostomy becomes a useful palliative operation that often 
restores the patient to a condition of fair health and better nutrition 
for many months or even years, despite the presence of 
a carcinoma of the stomach. By producing an artificial pas- 
sage from the stomach to the intestine, and thereby facilitating 
the passage of the food from the stomach into the bowel, 
stagnation of the gastric contents is prevented, digestion diverted 
altogether into the intestine and there vicariously carried on 
with more or less completeness, despite the atrophy of the gas- 
tric mucosa. At the same time the irritation of the gastric car- 
cinoma by food and by irritating decomposition products that 
arise from food stagnation is prevented and hence its growth re- 
tarded. 

In carcinoma involving the cardiac end of the stomach, pro- 
vided dilatation of the cardia with bougies is not successful (and 
this measure only answers the purpose of keeping the cardia open 



DISEASES OF THE DIGESTIVE APPAKATUS 535 

temporarily) and in diffuse carcinomata of the stomach, the radical 
operation of gastrostomy must be thought of; for while the results 
of total extirpation of the stomach are not good and many early 
deaths have been reported from this operation, nevertheless, this 
procedure may constitute a palliative measure in extreme cases 
that may enable the patient to live in comparative comfort for 
several months afterwards. 

If it has been determined that resection of the carcinoma is Conditions un- 
impossible; if the motor power of the stomach is so good that ternal tr t™" 
gastroenterostomy appears a superfluous inroad; if the case is ment is indi- 
seen too late for a gastrostomy operation, in an advanced stage of ca e 
cachexia or with metastases in various organs; if recurrences of 
gastric carcinoma appear after an operation and it does not seem 
feasible to operate a second time; or, finally, if a patient afflicted 
with cancer of the stomach refuses an operation, then a number 
of dietetic and medicinal means of treatment must be resorted 
to, all intended to maintain the general nutrition of the patient 
and to relieve a variety of distressing symptoms that may arise in 
the course of the disease. 

The regulation of the diet in gastric carcinoma is one of the Diet 
most important tasks of treatment. No set rules can be formu- 
lated as in the case of ulcer, and the selection of the diet must be 
governed chiefly by the state of the motor function and the pep- 
tic power of the stomach, as determined by frequent analyses of 
the stomach contents, as well as by the appetite, the particular 
likes and dislikes of the patient and his general state of nutrition. 
In most cases a fairly liberal diet is indicated. Every attempt Liberal diet 
should be made to allow the patient to enjoy his meals. He should 
not, on the one hand, be forced to eat foods that he dislikes or 
that he knows do not agree with him even though such foods may 
be theoretically indicated, nor should he, on the other hand, be 
forbidden to eat articles that he craves and that he knows agree with 
him, unless they are absolutely harmful. 

To the latter class of foods belong all articles that undergo Harmful foods 
rapid fermentation; they are bad because in most cases of car- 
cinoma of the stomach there is, early in the disease, a deficiency 
or a lack of (anti-fermentative) hydrochloric acid and reduced 
motor power; or if these conditions are not present in the begin- No fermenting 
ning they are very apt to supervene sooner or later. In the sec- foods 
ond place, all articles of food that contain undigestible and me- 
chanically irritating husks, stems, pips, seeds, tendons, cartilage, 
skin and connective tissue must be considered detrimental to cases No indigestible 
of carcinoma of the stomach. In the same sense large meals should P artlcl es 
always be forbidden, because they overtax the failing motor and No lar £ e meals 



536 



DISEASES OE THE DIGESTIVE APPARATUS 



Aversion for 
meat 



Vegetable al- 
bumens 

Eggs 
Milk 



Gruels 
Bread 

Vegetables 

Fruits 

Fats 



Beverages 



Amount of 
liquid 



Dilute alco- 
holic liquors 



Hydrochloric 
acid and diges- 
tive ferments 



peptic powers of the stomach; consequently small meals at frequent 
intervals should be advised. 

Most cases of carcinoma of the stomach instinctively have an 
aversion for meat; this is presumably a reflection in the appe- 
tite of the hydrochloric acid deficit. Meats should, therefore, be 
given sparingly and their administration never forced. Only soft 
and easily digestible varieties, like chicken, squab, calves' brains, 
sweet-breads, a little raw, scraped beef or rare steak or chop, fish, 
meat jelly should be given. 

If meat is altogether distasteful, or if it is not well borne, al- 
bumen must be supplied by milk and vegetable albumens (neutrose, 
tropon) and eggs, the latter soft boiled, scrambled, poached 
or as omelet, not hard boiled or fried. Milk may be served as 
described under Ulcer, or it may be rendered more nutritious by 
strengthening it with condensed milk or milk powder ; or it can be 
given in the form of gruels made of wheat, rice, oatmeal, barley, 
flour, or of arrow-root, sago, tapioca. Bread should be given in the 
form of old bread, toast, zwieback or crackers, never as hot bread. 
Of vegetables and fruits, cauliflower, asparagus tips, fruit sauces, 
stewed fruits are permissible. Fats should be supplied not as 
animal fat but as vegetable or milk fat in the form of olive oil or 
mayonnaise on salad dressings, butter, cream or coca. There is a 
popular prejudice against the administration of fat in cases of 
carcinoma of the stomach, but it will usually be found that these 
patients can tolerate considerable quantities of fat without digestive 
disturbances. 

The amount of liquid that should be introduced depends upon 
the motor power of the stomach. If there is much stenosis with 
gastric dilation and stagnation of stomach contents, then the 
amount of liquids should be restricted and whatever beverages are 
administered should be given in small quantities. In extreme cases 
the ingestion of fluid by mouth, should be restricted to the mini- 
mum compatible with comfort, and the water demands of the 
organism supplied by rectal irrigation as described elsewhere. In 
many cases dilute alcoholic liquors can do no harm. In pronounced 
motor insufficiency, however, they are detrimental, because the 
alcohol attracts water into the stomach. 

The administration of hydrochloric acid and digestive ferments 
to replace the deficient hydrochloric acid and pepsin in the stomach 
is of doubtful utility. As discussed in full in the Section on 
Gastritis, hydrochloric acid unless given in very large quantities 
does not aid materially in the digestion of albumen. If it is used 
at all, therefore, it should be given in ten to twenty drop doses in 
100 cc. of water, immediately after eating, and in the same dose 
three or four times afterwards at hour intervals. The advantages 



DISEASES OF THE DIGESTIVE APPARATUS 



537 



that might possibly accrue from the administration of the hydro- 
chloric acid would, in cases of gastric carcinoma with motor 
insufficiency, be more than neutralized by the ingestion of abundant 
quantities of water that must be given with such large quantities of 
hydrochloric acid. Small quantities of hydrochloric acid are of 
very little value as a digestant unless we agree to attribute certain 
stomachic properties to the remedy administered in this way. If 
given as a stomachic, the drug is more useful when administered on 
an empty stomach half an hour or an hour before eating. If the 
motor power of the stomach is good, the administration of hydro- 
chloric acid, and particularly of the ferments, is altogether 
superfluous, as the digestion of the albumens can be fully carried 
out vicariously in the intestine. If on the other hand there is 
much stagnation of stomach contents on account of motor insuf- 
ficiency, then the small quantities of pepsin or pancreatin or papaya 
preparation, that might be added to the fermenting gastric con- 
tents, will not be efficacious. 

If it is desired to administer a stomachic, any one of the rem- 
edies previously mentioned may be given either alone or in com- 
bination with small doses of hydrochloric acid before each meal. 
The best stomachic of all, however, is removal of the stagnating 
stomach contents by lavage. The indication for lavage is im- 
paired motility of the stomach; so that in any case of carcinoma 
of the stomach, in which food is found after the normal period 
of digestion is over, methodic lavage should be instituted; in other 
words, if six or seven hours after a test dinner, or two hours after 
a test breakfast, coarse particles of food are found in the stom- 
ach contents, or, above all, if the stomach after a late supper pre- 
ceded by lavage, contains food particles on the next morning, then 
washing out the stomach contents is indicated. Unless the motor 
power of the stomach is impaired, however, lavage of the stomach 
is altogether superfluous, even if it is found by analysis of the 
stomach contents that the peptic power of the organ is greatly re- 
duced. 

In severe degrees of motor insufficiency, i. e., in those cases 
in which undigested food particles are found in the stomach in 
the morning, lavage should be performed early in the day and 
before the first meal is taken. If the patient cannot sleep on ac- 
count of the gastric distention, belching, pain or vomiting, that 
result from stagnation of the stomach contents, then lavage should 
again be performed immediately before retiring. In the milder 
forms of motor insufficiency, lavage is best done before the eve- 
ning meal, for, in this way, the residue remaining in the stomach 
from the midday meal, and possibly from the morning meal, is 
removed and the supper goes into a clean and empty stom- 



Stomachics 



Lavage 



Lavage super- 
fluous if motor 
power of stom- 
ach good 



Time of per- 
forming lavage 
in impaired 
motor power 



538 



DISEASES OF THE DIGESTIVE APPARATUS 



Lavage with 
medicated irri- 
gations 



Symptomatic 
treatment 



Vomiting 



Hematemesis 



ach, SO' that the evening meal can either be properly digested or 
can be propelled into the bowel in time without producing noc- 
turnal distress. 

Lavage of the stomach in carcinoma should be continued for 
a long time, best of all, throughout the course of the disease or 
until a gastroenterostomy is performed or possibly until ulcera- 
tion of a pyloric carcinoma occurs whereby a free passage from 
the stomach into the bowel may become re-established. 

Lavage performed before breakfast or before supper may be 
combined with the injection of stomachics into the stomach; or 
the wash water may be medicated with antiseptics like salicylic 
acid, boric acid, etc. The addition of these remedies to the wash 
water is, however, rarely necessary and, in most cases, altogether 
superfluous. 

In most cases of carcinoma of the stomach, if the proper diet 
is administered and lavage of the stomach is methodically insti- 
tuted special medicamentous treatment for the relief of symptoms 
is, as a rule, not required. 

Vomiting of large quantities of stagnating food material is 
effectually prevented by lavage, especially if the wash water is 
medicated with antifermentative remedies. If the vomiting is 
due to gastric hyperesthesia, cocaine administered as described 
heretofore, or chloroform water in teaspoonful doses frequent- 
ly repeated, may be used. Narcotics are rarely indicated, and 
if they are given at all they should be administered by rectum 
in suppository or enema, or hypodermically. The one serious ob- 
jection to the use of opiates is their tendency to produce constipa- 
tion. If the vomiting is persistent and does not yield to lavage 
and to a simple diet and the above named measures, then the 
stomach may have to be put at rest for a number of days by total 
abstinence from food, and nutrition maintained by rectal feed- 
ing. 

Bleeding from the stomach is rarely severe in gastric car- 
cinoma; it should be treated by administering a bland, non-irri- 
tating diet and by employing all those measures and remedies 
that have been described at length in the Section on Ulcer. The 
best remedy of all to stop oozing in ulcerating gastric 
carcinoma is adrenalin chloride administered in ten to twenty 
drop doses of a 1:1,000 solution, at one hour or two hour 
intervals. In severe cases that are particularly intractable, or 
in cases of ulceration by carcinoma, in which the ulcer erodes a 
large blood vessel, total abstinence from food must be insisted 
upon and the patient fed by rectum. Opiates are occasionally in- 
dicated, especially if there is much stenosis about the pylorus 
with violent peristaltic movements on the part of the stomach; 



DISEASES OF THE DIGESTIVE APPARATUS 



539 



for opium possesses the power of reducing or stopping this per- 
istalsis; its administration, therefore, in these cases aids in estab- 
lishing quiet and contraction of the walls of the stomach. Ex- 
ternally cold should be applied to the epigastrium either in the 
form of an ice poultice, an ice bag or repeated cold cloths. Hot 
applications are contra-indicated if there is much gastric hem- 
orrhage. 

The pain in carcinoma is usually relieved by the application Pain 
of heat to the epigastrium either in the form of hot poultices, 
hot cloths, a Leiter coil through which hot water flows, a ther- 
mophore (see index) or Priesnitz compresses. If the pain ap- 
pears only when the stomach is full, lavage, i. e., removal of 
the irritating stomach contents, bring about relief. Sympto- 
matically the pain may be treated by the administration of co- 
caine, by choloroform given in three to five drop doses 
on ice, and if there are signs of peritonitic irritation, by opium 
with atropine, administered hypodermically, by clysma or in sup- 
pository. 

The constipation in gastric carcinoma is best treated by ene- Constipation 
mas of soap and water, glycerin and water, or oil. Laxatives are 
rarely necessary; if any are employed, simple vegetable remedies 
like rhubarb or cascara may be given in the form of the com- 
pound rhubarb pill containing rhubarb, aloes and myrrh and pep- 
permint oil in the dose of four to eight grains, or as the fluid ex- 
tract of cascara in half to one teaspoonful doses in water. Mer- 
curial purges, drastics or salines should not be administered. 

Diarrhea in carcinoma of the stomach is usually due to the Diarrhea 
entrance of fermenting and decomposing stomach contents into the 
intestine. This fermentative form of diarrhea can generally be 
prevented by methodic lavage instituted to remove the stomach 
contents before it undergoes decomposition and enters the intes- 
tine. If this measure is not carried out, then the intestinal anti- 
septics that are discussed in full in the Section on Intestinal 
Catarrh are of use. Very severe diarrheas, finally, may have to 
be combated by the use of opiates. 



MOTOR INSUFFICIENCY OF THE STOMACH. 
TRIC DILATATION, GASTRIC ECSTASY, 
GASTRIC ATONY.) 



(GAS- 



The term motor insufficiency is employed to indicate that the Definition 
stomach cannot get rid of food within the normal time limit. 
This condition may be due to a reduction of the normal propul- 
sive power of the stomach wall, or to the presence of an obstacle 
at the pyloric orifice, or it may be due to an abnormally largp 



540 



DISEASES OF THE DIGESTIVE APPARATUS 



Motor insuffi- 
ciency 



Gastric ectasy 
and dilatation 

Megalogastria 



Gastric atony 



Atonic and 

hypertonic 

.gastrectasy 



Clinical dif- 
ferentiation 



amount of work imposed upon an otherwise normal gastric mus- 
culature. Motor insufficiency, then, primarily designates a per- 
version of function which may or may not be accompanied by 
changes in the size of the organ; for there may be motor insuf- 
ficiency when the stomach is still normal in size but the pylorus 
is stenosed, or even when, as in some form of gastric carcinoma and 
in cirrhosis of the stomach wall, the stomach is abnormally 
small. 

The terms gastric dilatation and gastric ectasy should be re- 
served for those cases of enlarged stomach in which there is mo- 
tor insufficiency. Simple enlargement of the stomach with- 
out impairment of its motor power is designated as megalo- 
gastria. 

Gastric atony means muscular weakness of the gastric walls. 
Wherever there is atony there is also muscular insufficiency and, 
as a rule, but not invariably, gastric dilatation (gastric ectasy). 
Gastric ectasy with atony of the stomach wall is called atonic 
ectasy. There is also a form of hypertonic ectasy in which the 
stomach is large and in which there is motor insufficiency, but 
in which the muscularis is hypertrophic and not atonic. This 
form of hypertonic ectasy occurs particularly in cases of stenosis 
about the pylorus in which the muscles of the stomach wall are 
submitted to persistent overwork. Sooner or later this form, too, 
develops into atonic gastric ectasy, especially if the obstacle about 
the pylorus is not removed. It will be seen, therefore, that gastric 
atony and gastric dilatation are closely related and that the latter 
may develop from the former. They have this in common that 
both are accompanied by motor insufficiency. 

For ordinary clinical purposes, the finer anatomic differen- 
tiation between motor insufficiency with ectasy or atony is super- 
fluous and the following practical method of differentiation suf- 
fices for therapeutic purposes: 

The stomach is atonic if it requires an abnormally long time 
to expel the food, but, nevertheless succeeds in getting rid of all 
or nearly all of its contents during this abnormally long period. 
As a result little occasion is given for stagnation of the stomach 
contents and for its fermentative decomposition. A simple atonic 
stomach should always be empty in the morning. In atony the 
stomach is only slightly enlarged if at all and its lower boundary 
should not extend further than the umbilicus when it 
is filled (e. g., with a 1,000 cc. of water). The stomach is dilated 
(gastric ectasy) if it always contains food particles in the morn- 
ing and if its lower boundary extends below the umbilicus; here 
stagnation of stomach contents and fermentative decomposition are 
the rule. 



DISEASES OF THE DIGESTIVE APPARATUS 541 

Inasmuch as gastric ectasy frequently results from and fol- 
lows atony, it is clear that intermediary stages between simple 
atony and atony with dilatation must needs be encountered. 

Gastric atony is often congenital. In most cases, however, it Congenital, ac- 
is acquired and constitutes a part phenomenon of general muscu- ^ uire a ony 
lar asthenia; thus gastric atony is encountered in many chronic 
cachectic states, after severe infectious diseases, in many disor- 
ders of the liver, the heart and the kidneys, occasionally 
in chlorosis and anemia, after mental or bodily exertion and 
sexual excesses, after poisoning with alcohol and tobacco and in 
a variety of functional and organic diseases of the central nervous 
S} r stem. 

Dilatation of the stomach, on the other hand, may, as men- Causes of dila- 
tioned above, develop from simple atony of the stomach superin- a 10n 
duced by any of the above causes, especially in cases that despite 
the weakness of the stomach walls, persist in over-eating and 
over-drinking. In most instances, however, gastric ectasy is due 
to the presence of some mechanical obstacle to the passage of 
food in the pylorus or upper duodenum, as for instance, car- 
cinoma, cicatricial constriction following ulcer or erosion, pyloric 
spasm with or without hypertrophy of the pyloric musculature 
from different causes, constriction or obturation of the pylorus by 
adhesions in the neighborhood or from compression from without 
by tumors, gall stones, etc. 

It will be seen from all that has been said that the causal Causal treat- 
treatment of motor insufficiency of the stomach with or without ment 
gastric atony or dilatation must take all these manifold factors 
into careful consideration. In many instances the primary 
cause cannot be removed or can be made to disappear only very 
slowly. In other cases the primary cause may be removed, but the 
motor insufficiency, i. e., the weak condition of the muscles of 
the stomach and enlargement of the organ persist. In all these 
cases active treatment directed towards improving the motor pow- 
er of the stomach ; towards preventing further dilatation and stag- 
nation of the stomach contents; above all, towards maintaining 
the patient's general nutrition, despite the existence of gastric 
ectasy, must be energetically instituted. 

The diet in all these cases should be of such a character, first, Diet 
that it imposes the minimum of labor on the stomach whose mo- 
tor power is impaired; second, that it can be propelled easily and 
rapidly into the intestine; third, that it contains none of the General con- 
articles that can undergo ready gaseous or acid decomposition in side rations 
the stomach when they stagnate there ; fourth, that it is sufficient- 
ly nutritious to sustain the patient. In selecting the proper diet 
the state of the gastric secretion must be taken into consideration 



542 



DISEASES OF THE DIGESTIVE APPARATUS 



Fermentative 
dyspepsia 



Diet in 



Lactic 
fermentation 



in addition to the degree of motor insufficiency. The composition 
of the food will, therefore, have to vary according to the presence 
or absence of sufficient or over-abundant hydrochloric acid and pep- 
tic ferments. 

From a therapeutic standpoint, it is important to distinguish 
two forms of fermentive dyspepsia with motor insufficiency. The 
first form is due to derangement of the digestion of albuminous 
foods alone. Here we have heart-burn, eructations, vomiting of 
food and bile, a coated tongue, reduced appetite, emaciation, con- 
stipation and diminution of free and combined hydrochloric acid, 
an increase of the organic acids and an increase of the ammonia. 

In the other form the digestion of all classes of food seems to 
be disturbed, and we have quite similar objective symptoms and 
in addition headache, great depression, complete loss of appetite 
with increase of the organic acids and an absence of free hydro- 
chloric acid. 

In the first variety the fermentable albuminous foods should 
be eliminated from the diet, that is, milk, egg, meat and fish, while 
the proteid ration should be supplied by vegetable albumins; 
bread and bread stuffs, cereals should be forbidden. The foods 
should not be cooked with fat of any kind but some butter may 
be eaten with the food. In case the fermentation is chiefly of a 
lactic acid character the following prescription is very useful: 



v 



Ammonium fluorid, 0.3 

Distilled water, 300.0 

M. S. A tablespoonful after dinner and after 
supper. 



Butyric 
fermentation 



If the fermentation is of a butyric character the following pre- 
scription is useful: 



V 



Erythrol, 0.03 

Magnesia usta, 10.00 

M. S. This quantity to be taken twice during 
the day. 



If there is much vomiting the stomach should be thoroughly 
cleansed by lavage and very little food administered for 24 hours. 
The following prescription will be found useful in such irritative 
cases : 



DISEASES OF THE DIGESTIVE APPARATUS 543 



Picrotoxin, 






0.05 


Alcohol qs. ad solut., 


. 






Morphine muriat., 






0.05 


Atropine sulph., 






0.01 


Ergotin, 






1.00 


Aqua laurocerasi, 






12.00 


ML S. 5 drops before 


eating in 


water. 





If the secretion of hydrochloric acid is normal or increased, Diet with nor- 
then there is no objection to the use of meats and other albn- crea sed HCU 
urinous foods, inasmuch as these are promptly digested in the 
stomach; at the same time, especially in hyperchlorhydria, the 
ingestion of amylaceous foods should be reduced; for the diges- 
tion of the latter is always impeded in hyperchlorhydria, so that 
they are apt to undergo abnormal decomposition when they re- 
main in the stomach in an undigested state for an abnormally 
long time. 

If the secretion of gastric juice is reduced no meats at all Diet with re- 
should be given, but eggs, milk and mushy, amylaceous foods, 
i. e., gruels, made of milk with wheat flour, rice, barley, tapioca 
or sage, milk toast, vegetable purees, fruit sauces, butter, cream 
and olive oil may be administered. 

Large meals should always be avoided and all of the articles No large meals 
enumerated above should be given in small quantities at frequent 
intervals. The amount of food and its consistency, depend in 
one important group of cases upon the degree of stenosis at the 
pylorus, and one may say axiomatically that ijhe greater the 
obstacle to the passage of food through the pylorus the smaller 
should be the quantity of food that is administered at a time and 
the softer its consistency. 

From a practical standpoint it is best to experiment some- 
what in each case, i. e., to determine at frequent intervals by 
actual removal of the stomach contents after a mixed meal, which 
foods of the different kinds are retained and which are evacu- 
ated from the stomach within the normal time limits. In com- 
bination with such a motility test a study of the state of the Motility test 
gastric secretion may advantageously be made and the selection of f or feeding 
the diet somewhat regulated accordingly. 

All articles of food that are coarse in texture, that contain No coarse 
indigestible parts like tendons, skin, connective tissue, in the case 
of meats; stems, husks, skins, pips, seeds, in the case of vege- 
tables and fruits, should be altogether forbidden. Carbonated bev- Carbonated and 
erages that distend the stomach are always bad. Alcoholic liquors, qu0 rs to be 
solutions of albumoses and peptones, very salt foods, very sweet avoided 



544 



DISEASES OF THE DIGESTIVE APPARATUS 



Reduction of 
liquid intake 



Danger of 
tetany 



Administration 
of fluids by 
rectum 



Occasional to- 
tal food ab- 
stinence 



Rectal feeding 



Rest after 
meals 



foods and sugar solutions are forbidden, because they all draw- 
water into the stomach and hence over-burden the organ. 

The total liquid intake should be somewhat reduced. A dry- 
diet is not, however, advantageous, the claims of certain clini- 
cians to the contrary notwithstanding, for the propulsion of semi- 
liquid and mushy foods is always easier in motor insufficiency 
than the propulsion of a dry stomach contents. There is, there- 
fore, no objection to the introduction of small quantities of fluid 
with the meals nor to the employment of a liquid diet admin- 
istered in reasonably small quantities, provided the liquids ad- 
ministered are nutritious, i. e., consist of milk, albumen solutions, 
strong soups, for the latter are propelled from the stomach as 
easily as mushy foods and more easily than solid foods of equal 
nutritive value. Too great restriction of the liquid intake may 
lead to a dehydration of the tissues manifesting itself by a strong 
sensation of thirst and theoretically, at least, in severe degrees of 
motor insufficiency by tetany. 

Excessive dehydration resulting from great liquid restriction 
that may be necessary in some cases must be forestalled there- 
fore by the administration of fluids by rectum, as described else- 
where, and this procedure is always indicated when the total liquid 
intake is reduced below 1,000 cc. in the twenty-four hours. In 
very advanced stages of gastric ectasy with serious stenosis, the 
ingestion of liquids may have to be reduced even below this mini- 
mum and in such cases rectal administration of liquids will have 
to be instituted several times a day. 

Occasionally total abstinence from food for a few days great- 
ly aids in restoring some tone to the stomach ; for when the gastric 
walls are spared all labor one may assume that the muscularis 
recuperates under this rest treatment. In such cases the patient 
may be fed for a number of days to great advantage by rectum 
alone. Eectal feeding, too, has a place in many cases to supple- 
ment the insufficient food administration by mouth. In cases 
of gastric ectasy that are being prepared for operation rec- 
tal feeding too may be instituted for several days preceding the 
operation. 

Best after meals is a very essential element of the treatment. 
If the patient lies down after each feeding a larger proportion of 
blood determines towards the digestive tract than if the patient 
moves about; for, in the latter case much of the blood is drawn 
to the periphery, so that digestion may be somewhat impeded 
thereby. At the same time the erect position, especially when 
combined with active exercise, determines dragging and disten- 
tion of the stomach when it is full of food and heavy, and, in 
this way, favors the further development of atony and dilata- 



DISEASES OF THE DIGESTIVE APPARATUS 545 

tion. It is best to advise such patients to lie down for half an 

hour or an hour after each meal, preferably on the right side, 

as this facilitates the movements of the food toward the bowel. 

If there is an ulcer at the pylorus and much dilatation of the Position to be 

stomach, the latter position may, however, be hard to maintain \yf^S ^down ^ 

on account of the pain and distress produced by the pressure of 

the food on the ulcerated area. In such cases the dorsal position 

is preferable. The evening meal should never be eaten too near 

bedtime, as digestion is less active during sleep and hence 

food may remain abnormally long in the stomach during the 

night. 

Lavage of the stomach should be instituted in all cases of Lavage 
motor insufficiency according to the principles enunciated in a 
preceding section. In simple atony without ectasy and with 
mild degrees of motor insufficiency, lavage may occasionally be 
dispensed with. In gastric ectasy due either to atony or stenosis, 
lavage, however, is of the greatest value. By instituting methodic 
lavage an attempt is made to re-establish physiological conditions; 
this applies in particular to those cases of motor insufficiency in 
which food is still present in the stomach in the morning; for 
normally the stomach should always be empty at this time and it 
should enjoy several hours of rest during the night. In order Time for per- 
to promote this object the evening meal should be taken, as stated ormln & av age 
above, several hours before retiring, preceded by a lavage; for, 
in this way any residue that may have accumulated from break- 
fast or dinner will be removed and the supper, which should be 
light, is introduced into a clean stomach containing no ferment- 
ing food particles. Such a supper should be digested within 
three or four hours. If it is found that the stomach contains food 
particles in the morning, even when this plan is adopted, or if 
the patient suffers much distress at night from distention of 
the stomach with gases, then it may be necessary to perform lav- 
age before going to bed. In still other cases in which only very 
little residue is found in the morning, the stomach may be washed 
out before breakfast and again before supper. In most cases the 
afternoon lavage, six or seven hours after the heaviest meal, is 
sufficient. 

Lavage of the stomach should be very thorough and should be Medicated 
performed both with the patient sitting up and lying down. avage 
Washing the stomach with anti-fermentative solutions like a three 
per cent, boric acid solution ; two pro mille salicylic acid solution ; 
two per cent, resorcin solution; two pro mille hydrochloric acid, 
and other drugs, is occasionally useful. The objection advanced 
against frequent lavage, viz. : that nutritious material is thereby 
removed from the stomach, is more than over-balanced by the ad- 



546 



DISEASES OF THE DIGESTIVE APPARATUS 



A ddition of 
drugs to 
douche 



Bandaging the 
abdomen 



vantages accruing to gastric digestion from the removal of stag- 
nating particles and the introduction of new pabulum into a clean, 
empty stomach, 
touching In combination with the morning lavage, douching of the 

stomach may be instituted. This consists in forcing through a 
stomach tube containing numerous small openings, water, of eighty 
to ninety degrees Fahrenheit, under considerable pressure. Water 
injected into the stomach in this way hardly reaches all parts 
thereof, but the temperature of the water seems to exercise a tonic 
effect upon the weakened gastric musculature. This method of 
treatment is applicable chiefly to cases of gastric atony without 
much dilatation; but in gastric ectasy the injection of much wa- 
ter into the stomach under pressure is not good. The addi- 
tion of medicaments to the douche water is hardly nec- 
essary. Stomachics added to the douche, if the secretion of 
gastric juice is reduced and the appetite is impaired, 
can do no harm. If the hydrochloric acid is low sodium chloride 
in the proportion of ten grammes to the litre may be used. If 
there is hyperchlorhydria, a silver nitrate solution of the strength 
of 1:1,000 is useful. 

In order to lend support to the stomach, especially in cases 
in which the abdominal parietes are relaxed, and in general gastro- 
and entero-ptosis combined with gastric ectasy, bandaging the ab- 
domen is of some value. Abdominal supporters and bandages 
hold up the abdominal contents and thereby support the stom- 
ach; dragging and tugging on ligaments is prevented and conse- 
quently various reflex irritations that may react unfavorably upon 
the tone of the stomach walls eliminated. An abdominal supporter 
in order to do any good at all should fit correctly. Some cases 
of gastric dilatation cannot bear abdominal binders on account of 
the pressure they exercise upon the stomach, especially when it is 
full or distended with gas. 
Electricity To stimulate the tone of the atonic gastric musculature, elec- 

tricity applied in different ways has been used. Personally, I have 
abandoned its employment, as its administration, especially by 
the intra-gastric method, is rather complicated and usually dis- 
agreeable, and because nothing can be accomplished by the means 
of electric treatment that cannot be brought about equally well 
or better by other simpler means. In advanced stenosis of the 
pylorus, moreover, in which the gastric wall is not atonic, it is 
not good practice to over-stimulate the gastric musculature; for 
the latter is already working to the limits of its powers, as mani- 
fested often by the appearance of visible peristaltic waves in the 
region of the stomach. 



DISEASES OF THE DIGESTIVE APPARATUS 547 

Either the faradic or galvanic current may be used. Static Technique of 
electricity is rarely employed. The faradic or galvanic current Sj^jjIJ " thera * 
may be applied either by the percutaneous (extra-gastric) method 
or by the intra-gastric method. If the motor power of the stom- 
ach is to be stimulated a faradic current applied percutaneously is 
the best. It should be applied by means of two large sponge elec- 
trodes, one of which is laid directly over the stomach, the other 
one about an inch removed from the right edge of the first elec- 
trode along the right side of the body. The current should be 
strong enough to produce muscular twitchings of the abdominal 
muscles but only very slight pain. The faradic current should 
not be applied in this way for longer than ten minutes. For the 
relief of sensory symptoms the galvanic current applied by the 
intra-gastric method is the most effective. A great variety of 
gastric electrodes have been described. The simplest one is a 
spiral wire with a knob at the end which can be pushed through 
an ordinary stomach tube. Before applying galvanic electric- 
ity by the intra-gastric method, the stomach should be filled 
about one-half with water in order to prevent burning of its walls 
by direct contact with the electrode. The anode should be con- 
nected with the intra-gastric electrode, the cathode with a large 
plate electrode which should be applied over the sternum or to 
the back. A weak current should be used and the treatment 
should not last longer than ten minutes. If the intra -ventricular 
treatments cannot be carried out, then either the galvanic 
or faradic current may be utilized for the relief of sensory symp- 
toms by applying one large electrode connected with the anode 
over the epigastrium, another one connected with the cathode over 
the back or sternum. 

In skillful hands massage of the stomach is of some use ; this Massage of the 
measure, however, is, as a rule, superfluous. It is expected to stomac " 
fulfill two objects, namely, to strengthen the musculature of the 
stomach and to propel the gastric contents onward; the former 
object, owing to the inaccessibility of the stomach is probably 
very difficult to attain and therefore the value of massage in this 
direction is highly problematical. The latter effect is, at best, 
merely palliative and is, self -evidently, altogether fictitious and, 
at best, transitory, unless carried out immediately after each meal. 
There are, moreover, definite contra-indications to the use of gas- 
tric massage, notably the presence of an ulcer, the occurrence of a 
recent hemorrhage and perigastric adhesions. 

Of general hydrotherapeutic measures the Scottish douche i. e., Hydrotherapy 
the application of a strong stream of water, the temperature of 
which is changed every twenty or thirty seconds from hot to cold, 
is the most useful. Fan douches, too, are of some value. Pries- 



548 



DISEASES OF THE DIGESTIVE APPAKATUS 



Medicamentous 
treatment 



Constipation 



Vomiting 



Oil cure 



Surgical treat- 
ment 



Indications for 
surgery 



nitz compresses in many cases exercise a soothing effect and slight- 
ly stimulate contractions of the gastric muscles. 

Of drugs that are used to improve the tone of the gastric 
muscles, tincture of nux vomica or strychnia are the most popular. 
Tincture or extract of nux vomica should be given by mouth 
before meals or in the morning on an empty stomach with 
the stomach douche. Strychnine is best given hypodermic- 
ally. 

Constipation and vomiting should be treated by the use of 
enemata, mild vegetable laxatives like rhubarb and caseara, and 
by abdominal massage (see index) ; mineral waters are, of course, 
to be eschewed. 

Vomiting generally yields to the proper regulation of the diet 
and to lavage. Priesnitz compresses or hot poultices to the epi- 
gastrium are frequently of value and if the vomiting is due to 
hyperesthesia of the gastric mucosa, cocaine or narcotics 
administered in suppositories or hypo dermic ally may be 
used. 

A useful procedure finally, especially in pyloric spasm with 
resulting stenosis and motor insufficiency, is the so-called oil cure. 
It consists in the administration of 50 cc. of oil three times a 
day, half an hour before eating, or of 150 cc. of olive oil on an 
empty stomach in the morning, either swallowed or adminis- 
tered through a stomach tube. This latter treatment frequently 
stops the spasmodic closure of the pylorus, facilitates the passage 
of the gastric contents into the bowel, exercises a slight laxative 
action which effectually counteracts any tendency to constipation 
and, at the same time, aids in nourishing the patient. 

Surgical treatment often becomes necessary in advanced de- 
grees of motor insufficiency. It may consist either in removal of 
the obstruction at the pylorus, in drainage of the stomach by 
gastroenterostomy, in mechanical reduction in the size of the 
stomach or in producing mechanical changes in the size or the po- 
sition of the stomach. 

The indications for surgical intervention are the following: 

First, the discovery of some mechanical obstruction to the 
passage of the food from the stomach into the intestine, especially 
if this obstruction remains persistent for a long period of time 
or if it increases, or if it is due to a malignant growth. 

Second, if the motor insufficiency, atony and ectasy grow 
worse instead of better, despite the treatment outlined above. 

Third, if despite all treatment and the apparently successful 
relief of symptoms, including the motor insufficiency, the nutri- 
tion of the patient becomes impaired and weight is lost. 



DISEASES OF THE DIGESTIVE APPARATUS 549 

Fourth, if the patient does well under continuous treatment, 
but grows worse as soon as persistent treatment is stopped. In 
such, cases, especially if the physician is convinced that the patient 
could not improve unless treatment were continuously carried out, 
an operation may become necessary. 

The methods of removing pyloric obstruction by resection, Surgical 
pyloroplasty, etc., need not be discussed in this volume. The me ° s 
indications for resection of the pylorus in carcinoma have already 
been formulated. In many cases, especially those in which the 
motor insufficiency and dilatation are far advanced, gastroen- 
terostomy is, by all means, the best operation; for in some cases 
even the re-establishment of a patency of pylorus would not re- 
store the motor tone to the stomach. Sewing tucks into the 
stomach is a useful procedure only in mild degrees of atony in 
which the stomach muscles still retain some contracting and pro- 
pelling power. G-astroplication, shortening of the gastric-hepatic 
omentum, or of the gastric-hepatic and gastric-splenic ligaments, or 
fixing the stomach in a position where drainage through the py- 
lorus becomes better, either by stitching or by making a sling of the 
lesser omentum sewed to the pancreas for the stomach to rest on, 
are methods of surgical treatment that have all been tried. All 
of the latter are applicable only to cases of motor insufficiency 
with dilatation due to atony, not to dilatation due to stenosis 
about the pylorus. It is altogether too early to pass definite judg- 
ment on the efficacy of these different, rather complicated, surgical 
procedures. 



GASTRIC HYPERSECRETION AND HYPERCHLOR- 

HYDRIA. 

These two conditions may be discussed together although they Definition 
occasionally produce somewhat different symptoms and may call 
for somewhat different treatment. In hypersecretion the gastric 
glands secrete gastric juice in excess when they are stim- 
ulated by the food, but they may also do this when they are not 
stimulated by the food, i. e., when the stomach is empty; con- 
sequently in this condition the stomach contains abundant gas- 
tric juice nearly all the time. Hypersecretion obviously is always 
accompanied by hyperchlorhydria, but the latter condition may 
also occur as an independent affection without hypersecretion, 
and manifest itself by an excessive out-pouring of hydrochloric 
acid only when the stomach contains food. The two conditions, 
it will be seen, are closely related, the difference between them 
being more of degree than of kind. Hypersecretion may be con- 



550 



DISEASES OF THE DIGESTIVE APPARATUS 



Causes 



Causal treat- 
ment 



The diet 



Articles 
avoided 



to be 



Abundant al- 
bumen 



sidered as a continuous form of hyperchlorhydria occurring with- 
out the stimulus of food; hyperchlorhydria as a periodic form of 
hypersecretion and one that requires the stimulus of food to be 
produced. 

Hypersecretion and hyperchlorhydria may be a part phenom- 
enon of a general neurosis; they may follow mental, emotional 
over-strain or psychic shock; they may occur in the course of 
chlorosis; they may result from abnormal irritation of the gas- 
tric mucosa, if dietetic indiscretions, especially accompanied by 
the abuse of alcohol, tobacco, very hot foods, spiced foods, are 
committed; or they may be seen in anatomic lesions of the stom- 
ach or may finally constitute a reflex phenomenon emanating from 
remote organs of the body. 

The causal treatment, therefore, of hypersecretion and hyper- 
chlorhydria must take all these elements into consideration. If 
the patient is a neuropath, then the neurasthenic or hysterical con- 
dition should be treated as described in the Section on Gastric 
Neuroses. 

All emotional or mental over-strain should be avoided, any 
condition of anemia or chlorosis corrected, bad habits of eating 
improved and all factors that may become operative to irritate 
the gastric mucosa and the secretory nerves of the stomach, either 
directly or by reflex irritation, sought for and, if discovered, re- 
moved. 

Inasmuch as the out-pouring of excessive gastric juice with an 
abnormal amount of hydrochloric acid is in most cases due to 
the stimulating effect of food which in these patients produces a 
quantitatively abnormal secretory reaction, the selection of the 
proper diet is of paramount importance. The diet, while ade- 
quately nourishing the patient, should be mechanically non-irri- 
tating, i. e., it should contain no coarse and indigestible particles 
like skin, tendons, cartilages, husks, seeds, pips, etc. It should 
contain no spices or condiments (mustard, pepper, paprica, 
cloves, etc.) ; nor any fruits or vegetables incorporating irritat- 
ing oils (onions, radishes, horse-radish, etc.) ; nor should very 
acid foods, very hot foods, nor strong alcoholic drinks be admin- 
istered. 

One of the most important and useful dietetic measures is to 
put patients with gastric hyperchlorhydria upon a salt-free diet. 

The diet should contain abundant albuminous pabulum; for 
the latter, owing to its power to combine with hydrochloric acid, 
acts as an antacid and thereby gives symptomatic relief. The vari- 
ous albuminous foods differ in their power to bind hydrochloric 
acid. 



DISEASES OF THE DIGESTIVE APPARATUS 551 

Best of all among the meats are beef, mutton and raw ham Meats 
(Fleischer), but other forms of meat or fish or poultry are suit- 
able food for these cases, provided they are not served in the 
form of cured, spiced or corned meats; for meats prepared in this 
way, on account of the spices, salts and extractives they contain, 
directly stimulate the flow of hydrochloric acid. 

The selection of the meats must also be governed somewhat Selection of 
by the presence or absence of motor insufficiency, atony, or dila- ^^ S or m a b^en S ce 
tation of the stomach. If the stomach does not empty itself with- of motor in- 
in a normal time (and in hyperchlorhydria it usually empties su cienc y 
itself more rapidly than normal, especially if an albuminous diet 
is administered), then all coarse varieties of meats should be 
avoided. If there is no motor insufficiency, then coarse meats are 
particularly useful, as they require much hydrochloric acid for 
their digestion and hence possess relatively great hydrochloric acid 
binding properties. 

In hypersecretion or hyperchlorhydria associated with motor 
insufficiency or ectasy, finely divided meat, i. e., scraped or hashed 
meat, milk in small quantities and given at frequent intervals, and 
eggs are the best albuminous foods. Milk, gruels and soups made 
with flour of rice, wheat, barley, or with arrow-root, tapioca, sago, 
eggs; or milk rendered more nutritious by the addition of con- 
densed milk or milk powder (see index) are all useful additions 
to the meat diet. 

Starchy foods are digested with difficulty in the stomach in Starchy foods 
hyperchlorhydria and hypersecretion. This is due to the fact that 
in hypersecretion, free hydrochloric acid is either present, when 
the food enters the stomach or appears there earlier than normal 
in simple hyperchlorhydria, so that it interferes with the amylolytic 
digestion of the starches in the stomach by inhibiting the action of 
the saliva that is swallowed. Starchy foods, therefore, unless 
promptly evacuated into the bowel, undergo abnormal fermenta- 
tion and lead to the formation of irritating organic acids in the 
stomach; moreover their digestion in the bowel is interfered with 
as they enter the intestine in an hyperacid medium that must first 
be neutralized and rendered alkaline by the intestinal juices before 
the latter can digest starchy pabulum; for this reason amylaceous 
foods should never be given on an empty stomach in the disease 
under discussion and should always be given in relatively small 
quantities together with, or better still, after an abundant proteid 
diet. 

The assimilation of starchy foods is greatly facilitated by ad- Dextrinized 
ministering them in a dextrinized, i. e., partially predigested, car y ra es 
form, as malted foods, toasts, zwieback or as dextrose. The lat- 
ter especially as it is readily absorbed from the gastro-intestinal 



552 



DISEASES OF THE DIGESTIVE APPARATUS 



Dextrose solu- 
tion 



Cane sugar 



Preparation of 
starchy foods 



Fats 



Beverages 



Alkaline min- 
eral waters 



tract, does not stimulate the hydrochloric acid secretion as much 
as other carbohydrate foods, so that the carbohydrate requirement 
of the organism can very well and safely be satisfied by the admin- 
istration of dextrose in ten to twenty per cent, watery solution, 
given at frequent intervals. In atony or ectasy of the stomach 
with stagnation of stomach contents, dextrose solution, however, 
should not be given, especially as it possesses the power to some 
degree of drawing water into the stomach, an event that, as stated 
in a previous section, is to be especially avoided. Cane sugar is 
by far less useful than dextrose, for the former must first be in- 
verted into dextrose and levulose before it can be assimilated, and 
this process occurs with great difficulty in an acid medium, or in 
a medium that is only slightly alkaline. 

The mode of preparing amylaceous foods is important; the 
carbohydrates are best administered in the form of vegetable 
purees, mashed or baked potato, fruit sauces or in the form of dif- 
ferent flours, with milk, as gruels or mushes as described above. 
Raw, stringy, coarse or acid vegetables or fruits, fresh or coarse 
breads, cereals containing husks should be carefully avoided. 

Fats never do any harm in hyperchlorhydria and hypersecre- 
tion if given in a digestible form ; butter, cream, vegetable oils are 
all useful foods, whereas the animal fats, being less digestible, 
should be given very sparingly. Only fats with a low melting point 
should be used. Tallow and lard and meat fats generally should 
be avoided. Particularly useful are fats made from nuts, hence 
preparations made from finely ground almonds are particularly 
valuable. Certain theoretical objections have been formulated 
against the administration of fats. The claim in particular has 
been advanced that they, too, require an alkaline medium for their 
digestion in the intestine and that in hyperchlorhydria and hyperse- 
cretion such a medium is not created as soon as it normally should 
be. These objections are overthrown by practical experi- 
ence. The high caloric value of the fat, the empiric fact that they 
are well digested in the intestine and that they are well borne, 
despite the existence of hyperchlorhydria, especially if they are ad- 
ministered together with abundant proteid, renders them very 
useful additions to the diet in nearly all cases. If there is com- 
bined with hyperchlorhydria or hypersecretion an advanced degree 
of motor insufficienc}^ especially if gastrectasy is present, then 
they should, of course, be given sparingly. 

Fluids, provided there is no gastric atony or ectasy, may be 
given abundantly. They act very well symptomatically by diluting 
the hyperacid gastric juice without interfering with the diges- 
tion of the albumens. Alkaline mineral water, especially the car- 



DISEASES OF THE DIGESTIVE APPARATUS 553 

bonated varieties, are especially useful as table beverages; 
for they combine antacid properties with slightly anesthetic 
powers (C0 2 ) and are consequently particularly useful when 
hyperchlorhydria is associated, as it so often is, with gastric 
hyperesthesia. That carbonated beverages should not be used in 
gastric atony or gastrectasy need hardly again be empha- 
sized. 

Alcoholic liquors, tea and, above all, coffee, should be forbid- Alcoholic li- 
den, for they all somewhat irritate the stomach and stimulate the ^° rs ' ea ' 
flow of gastric juice. Smoking, too, is best forbidden altogether. Smoking 

Small meals containing abundant proteids, given at frequent Small meals at 
intervals are better than large meals given at longer intervals, ^vals 111 m " 
If small meals are administered over-secretion of gastric juice may 
often be avoided. It is a very good rule, however, never to let the Stomach 
stomach, in these cases, become altogether empty at any time dur- beemotv^ 1 
ing the day. The patient may have a breakfast, dinner and sup- 
per of moderate volume at the regular times, but should, in addi- 
tion to these three main meals, drink a glass of milk or eat a soft 
boiled egg or two with a cracker or a piece of toast in the middle of 
the forenoon, in the middle of the afternoon and on retiring. If 
patients suffering from advanced degrees of hypersecretion or hy- 
perchlorhydria complain of much pain or distress during the night, 
on account of the presence of free hydrochloric acid in the stomach, 
then a glass of milk taken in the middle of the night is often of the Night feeding 
greatest value in relieving this very disagreeable symptom. 

Lavage of the stomach is of relatively small value in hyper- Lavage 
secretion and hyperchlorhydria unless there is some motor in- 
sufficiency. In cases that suffer from nocturnal distress, as de- 
scribed above, washing out the stomach with a dilute alkaline solu- 
tion just before retiring, is however, often of value. 

Douching the stomach (see index), after a cleansing lavage in Douching 
the morning, with a 1:1,000 silver nitrate solution or a two Silver nitrate 
per cent, boric acid solution is also often of some value. 100-200 Boric acid 
cubic centimeters of the silver nitrate or boric acid solution are 
left in the stomach for two to five minutes and then washed out 
with water. The silver nitrate, in particular, seems in some cases 
to reduce the secretion of gastric juice for the rest of the day; 
at the same time it acts somewhat as an anesthetic to the irritable 
gastric mucosa, so that the silver nitrate treatment is of especial 
value in hyperesthesia of the stomach. 

Of other remedies that can suppress the secretion of gastric Remedies to 

suppress HC1 
juice, belladonna and atropine are the most important. The for- excretion 

mer given as the extract in combination with an alkali is often of Belladonna 

signal value. The following prescription is useful: Atropine 



554 



DISEASES OF THE DIGESTIVE APPARATUS 



3 



Alkalies 



Sodium bicar- 
bonate 



Magnesia usta 
and magnesium 
carbonate 



Extract of belladonna, 

Burnt magnesia, 

M. Fifteen such powders. 

Sig. One three times a day after eating 



0.03 g.m. 
0.5 gm. 



(Ortner.) 



Atropine is best given hypodermically in doses of from one 
hundredth to a fiftieth of a grain, once a day, in the morning. 

Peroxide of hydrogen in a half per cent, solution and in the 
dose of 1 cc. given two or three times daily, exercises a most marked 
effect upon the secretion of gastric juice. 

Alkalies are, as a rule, indispensable in the treatment of hyper- 
chlorhydria and hypersecretion. The chief object of administer- 
ing them is to neutralize the excessive hydrochloric acid that is 
poured into the stomach. In order to be effective they must be 
given in large doses after meals, at the period when digestion is 
at its height. In hypersecretion it may be necessary to give 
them also when the stomach is empty, i. e., before eating or in 
the middle of the night in order to neutralize the acid that is 
present at that time. Sodium bicarbonate is the most popular 
alkaline remedy, but it should be used with some care as it is 
slightly irritating to the mucosa. The copious development of 
carbon dioxide is generally distressing to the patient on account 
of the gastric distention and belching it produces and may even be 
dangerous in ulcer. The sodium chloride that is formed, more- 
over, somewhat stimulates the secretion of hydrochloric acid. 
It will be seen, therefore, that the popularity of sodium carbonate 
is not deserved. 

Far better as antacids are magnesia usta or magnesium carbon- 
ate. Magnesia usta is probably the best remedy of all, for it is 
non-irritating to the stomach, it is capable of binding nearly four 
times as much hydrochloric acid as an equal bulk of sodium car- 
bonate, and the magnesium chloride that is formed does not stim- 
ulate the hydrochloric acid secretion in the stomach. Magnesia 
usta, moreover, possesses the power of binding any C0 2 that may 
be formed from fermentation in the stomach, and, finally, magnesia 
salts possess slightly laxative properties that are useful in order 
to counteract any tendency to constipation. 

The following mixture of sodium carbonate and magnesia espe- 
cially is very useful and answers all purposes in practice : 



K 



Sodium cabonate, 

Burnt magnesia, of each, 

Sugar of milk, 



100 parts 
150 parts 



DISEASES OF THE DIGESTIVE APPARATUS 555 

This mixture should be procured in bulk by the patient and 
should be taken in half to one teaspoonful doses, in milk, at the 
height of digestion. 

Another good preparation is a compressed tablet containing Sodium bibo- 
equal parts of sodium carbonate and magnesium carbonate. The ra e 
administration in a compressed tablet favors slow solution of the 
alkalies in the stomach and hence somewhat prolongs their effect. Calcium ear- 
Moreover, this mixture leads to a very slow evolution of carbon ona e 
dioxide. Other antacids that can be used are biborate of soda and 
calcium carbonate in the form of precipitated chalk, given in a 
third of a teaspoonful dose at the proper times. 

There is much prejudice against the continuous administration 
of alkalies. Very rarely, however, are detrimental results witnessed, 
even if an alkali therapy is continued for long periods of time. 
There is still some difference of opinion in regard to the effect of 
alkalies upon the gastric secretion, some investigators claiming that 
it stimulates the flow of gastric juice, others that it retards it. If 
the alkali is properly administered, chemical irritation of the gastric 
wall can hardly occur. If soda bicarbonate is administered alone, 
there is greater danger than if it is administered in conjunction 
with calcium or magnesium salts (bivalent ions). In gastric ca- 
tarrh alkalies are to be given only in moderate doses. If it is de- 
sired to neutralize excessive acidity of the colon, simple alkalies 
like carbonate of magnesia must, of course, be administered. 

Carbonated alkaline waters (see above) and also saline waters Alkaline and 
are of considerable value in the treatment of hypersecretion and waters 6 " 8 
hyperchlorhydria. These waters are especially efficacious when Benefits of re- 
taken at certain watering places or resorts ; but a great part of the sort treatment 
good, effect observed from their use must be attributed to the care- 
ful regime that the patients follow at these resorts, to the respite 
from every-day cares and worries, to the agreeable psychic stim- 
ulus and suggestive effect that is granted when they visit these 
water places. The successful management of their cases, moreover, 
by resort physicians, who have much experience with this particular 
class of invalids plays an important role. The different 
waters administered at home are certainly less effective than 
when they are taken at watering places. 

GASTRIC HYPOSECRETION AND ACHYLIA GAS- 

TRICA. 

The reduction or the complete suppression of the gastric juice Causes 
may be a part phenomenon of a general neurasthenia or hysteria, 
or a symptom of various organic diseases of the stomach (carcin- 
oma, chronic gastritis, atrophy, amyloid degeneration), or it may 



556 



DISEASES OF THE DIGESTIVE APPARATUS 



Diet 



Presence or 
absence of 
motor insuf- 
ficiency 



The motor 
power is good 



The motor pow- 
er is impaired 



Pancreas 



Eggs, milk, 

vegetables 

Albumens 



attain the dignity of an independent neurosis. Simple hypo- 
acidity or anacidity are probably never seen. In most cases the 
secretion of the gastric enzymes, too, is reduced, so that it is more 
proper to speak of hypochylia and achylia. 

The most important element in the treatment of hypochylia 
and achylia gastrica is the selection of the proper diet. The reg- 
ulation of the food is dependent on the presence or absence of mo- 
tor insufficiency. If the motor power of the stomach is good, 
then every effort should be put forward to maintain it so, and all 
coarse and indigestible foods, large meals, large quantities of 
liquid should be avoided as a prophylactic measure. The patient, 
therefore, should receive small meals at frequent intervals, consist- 
ing of easily digestible meats, abundant carbohydrate and consid- 
erable quantities of fat. If the motor power of the stomach is 
impaired, especially if there is in combination with hypochylia and 
achylia gastrica some gastric atony or gastric ectasy, then 
the motor insufficiency becomes the more important element to be 
considered and it should be treated as described in a previous sec- 
tion. 

Provided the motor power of the stomach is good or only 
slightly impaired, then meats should be allowed. In selecting the 
kind of meat, its digestibility should be considered above all things 
(see preceding table), consequently broiled or stewed poultry, cer- 
tain varieties of fish, raw, rare, scraped or hashed beef, mutton or 
ham, calves' brains, sweet-breads, all finely divided and carefully 
freed from skins, tendons, etc., and administered in small quanti- 
ties, are permissible. 

If the motor power is seriously impaired, meats are best avoid- 
ed altogether, or, if given at all, administered in very small quan- 
tities; for one must realize that in the condition under discus- 
sion the digestion of albuminous pabulum in the stomach is very de- 
cidedly impaired or altogether inhibited; consequently serious 
harm can be done to the stomach unless the gastric contents can 
promptly be propelled into the bowel where the disassimilation of 
the albumens can be vicariously carried on by tryptic digestion. In 
certain cases in which the motor power is not too seriously im- 
paired, pancreas preparations can to advantage be administered 
together with small quantities of meat ; for in this way intestinal di- 
gestion is begun in the stomach and the disassimilation of 
the albumens aided. If there is some hydrochloric acid secretion, 
the pancreas preparations must, of course, be given with sufficient 
alkali to more than neutralize the gastric hydrochloric acid. 

What has been said of meats applies with equal force to other 
albuminous foods, i. e., eggs, vegetables rich in albumen and 
milk. Eggs should be given in a semi-liquid form or finely divided, 



DISEASES OF THE DIGESTIVE APPARATUS 



557 



Fruits and 
vegetables 



Fats 



i. e., either soft boiled, or poached or as scrambled eggs, or as 
chopped up hard boiled eggs. Vegetables should be given as 
purees. Milk must be given in small quantities only; for the in- 
gestion of abundant fluid, as stated above, is to be avoided. In 
allowing milk the tolerance of the individual for this food must 
always be determined by experiment, for by some patients with 
hypochylia and achylia gastrica milk is not well borne. 

Inasmuch as the digestion of the carbohydrates is in no way Carbohydrates 
impaired in hypochylia and achylia gastrica, they should consti- 
tute the major portion of the diet. 

The same rule in regard to the avoidance of coarse, bulky and 
indigestible ingredients applies to the administration of vegetables ; 
i. e., vegetables and fruits should be given in finely divided form, 
preferably as purees or fruit sauces and in small quantities after a 
careful removal of all coarse and indigestible stems, husks, seeds, 
pips, etc. Many starchy vegetables like rice, barley, sago, tapioca, 
arrow-root, wheat and oatmeal flour, etc., are best given with milk 
as gruels or mushes. Toast, bread, zwieback and crackers are all 
useful and permitted. 

Fats, especially butter, cream, cocoa and vegetable oils are 
allowed. Animal fats like bacon, lard and suet are less digestible 
than milk and vegetable fats and should consequently be given 
sparingly. Very large quantities of fat should never be given on 
account of the possible formation of irritating decomposition 
products. Moreover, large quantities of fat rapidly produce a sense 
of satiety and hence often impair the appetite and prevent the pa- 
tient, whose albumen ration is reduced, from ingesting sufficient 
nutriment to maintain adequate nutrition. 

In this class of cases many delicacies, spiced and salted foods, Delicacies 
meat extracts, albumose and peptone preparations have a place in 
the menu; for all these preparations slightly irritate the gastric 
wall and stimulate the flow of gastric juice. For the same reason 
small quantities of alcoholic beverages, either brandy or whisky 
with water, a little champagne, a light Moselle, Burgundy or claret 
are useful. 

Lavage of the stomach is rarely necessary unless there is, at 
the same time, an advanced degree of motor insufficiency. If the 
motor power of the stomach is impaired, then the same indications 
for lavage exist as in any other form of motor insufficiency. 

Douching the stomach with a 1 :100 salt solution is in some Douching 
cases a very useful procedure if persistently carried out; for the 
injection of salt into the stomach in this way seems to exercise 
a stimulating effect upon the secretion of hydrochloric acid. Douch- 
ing with salt solution is best performed early in the morning before 
breakfast or after a cleansing lavage. Many of the saline waters, Saline waters 



Alcoholic bev- 
erages 



Lavage 



558 



DISEASES OF THE DIGESTIVE APPARATUS 



Drugs 



Sodium bicar- 
bonate before 
meals 

Hydrochloric 
acid 

Stomachics 



Enzymes 



Neurotic form 



taken in small quantities on an empty stomach, answer the same 
purpose. 

The use of medicines to stimulate the flow of hydrochloric acid 
and of gastric enzymes is theoretically indicated, but practically 
very problematical. The administration of small quantities of 
sodium bicarbonate before meals is claimed to be an efficient means 
of stimulating a reactive flow of hydrochloric acid. This effect, 
however, is very doubtful. Hydrochloric acid given in small quan- 
tities, together with one of the stomachics before meals, is fully as 
useful. The use of hydrochloric acid even in large quantities after 
meals, or the use of peptic enzymes, is of doubtful utility as a sub- 
stitution therapy. If the motor power of the stomach is good the 
artificial ingestion of these gastric products is at least superfluous, 
because the intestine vicariously assumes peptic digestion; in fact, 
in such cases the administration of large quantities of hydrochloric 
acid by reducing the alkalinity of the intestinal juices may some- 
what retard try p tic digestion. If the motor power of the stomach 
is impaired, then lavage and other measures that have been dis- 
cussed in the Section on Motor Insufficiency are far more effective 
than the use of hydrochloric acid and pepsin. 

In the purely neurotic form of hypochylia and achylia gastrica, 
a variety of hydriatic measures, massage, electricity, the selection 
of a proper climate and resort and, to some extent, suggestive treat- 
ment are all useful. For all these methods, their exact indications 
and employment I refer to the next Section. 



Definition and 
causes 



In anatomic 
stomach le- 
sions 



Diet 



GASTRIC NEUROSES. 

To the category of gastric neuroses in the broader sense belong 
certain functional disturbances of the stomach that are produced 
by lesions of the stomach itself, but in which a marked dispropor- 
tion exists between the organic cause and the functional effect, indi- 
cating that some perversion must exist about the nervous apparatus 
governing the function that is perverted and causing it to react ab- 
normally to a stimulus that, in a healthy subject, would produce a 
(quantitatively) different reaction. 

Of recent years one has learned to understand that many pain- 
ful gastric disturbances commonly interpreted as gastric neuroses 
or gastric hyperesthesia are really due to arterio-sclerotic changes 
of the abdominal vessels. Here an examination of the whole car- 
dio-vascular apparatus is often of the greatest value and upon the 
discovery of the arterio-sclerotic changes the following treatment 
should be instituted: — 

In this category the diet should be very simple, very nourish- 
ing and very digestible, and each feeding should be as small as pos- 



DISEASES OF THE DIGESTIVE APPARATUS 559 

sible. The general hygiene should be carefully looked after, a prop- 
er balance struck between rest and exercise, and free evacuation of 
the bowels promoted. Medicamentous treatment, if directed in the 
proper channels, is often accompanied by very gratifying results. 
Vaso-dilators like diuretin, sodium nitrite and nitroglycerine are 
of great value, as described in a previous chapter. Probably the 
best remedy of all is diuretin given in doses of 0.5 to 1 g. three 
times a clay. To the same group belongs theobromin. 

Gastric neuroses proper, however, occur without any anatomic Without ana- 
changes about the stomach. In most cases they are of reflex origin i°5fo ns St ° m 
and superinduced by irritation of the gastric nerves from some re- 
mote diseased organ. In this class of cases, as well as in the first 
mentioned group, the stomach nerves must again be considered to 
be in an abnormal state of irritability. The two groups differ 
merely in this, that in the first reflex irritation emanates from some 
intra-gastric source, whereas in the second category the primary 
focus of reflex irritation lies outside of the stomach ; thus eye-strain, Reflex causes 
certain organic lesions of the brain, the cord, the meninges, disor- 
ders about the sexual sphere, intestinal parasites, violent pain any- 
where in the body, as for instance renal or hepatic colic, angina pec- 
toris, peritonitic pain from different causes, etc., may all produce 
gastric neuroses. 

In a third group of cases psychic causes, mental and emotional Psychic causes 
disorders, sudden emotional shock, depression, anger, fear, mental 
over-work all react on the innervation of the stomach and produce a 
variety of functional disorders. 

Finally, various intoxications as from lead, alcohol, morphine, Intoxications 
tobacco; infectious toxemias, notably in tuberculosis and malaria^ 
different forms of self-poisoning as uremia, acidosis, may all pro- 
duce functional gastric disorders that have no anatomic substratum 
in the muscular, sensory or glandular apparatus of the stomach. 

All these factors, as already indicated above, cannot, however, Neuropathic 
operate to produce gastric neuroses unless there exists as a basis a 1S P° S1 lon 
neuropathic disposition which may be either congenital or acquired. 
The diagnosis, therefore, of a gastric neurosis should never be made 
from negative evidence alone, i. e., on the ground that no anatomic 
gastric disorder is discoverable, but it should only be arrived at if 
to this negative evidence is added the positive discovery of general 
neuropathic stigmata in the afflicted subject. 

It is clear, therefore, that the diagnosis of a gastric neurosis Difficulty of 
should always be made with the greatest conservatism. It is prob- diagnosis 
ably never altogether positive but generally tentative and prelim- 
inary ; for, in many cases, one must realize that the discovery of an 
anatomic basis is impossible merely on account of the deficiency of 
our methods and on account of lack of skill or thoroughness on the 



560 



DISEASES OF THE DIGESTIVE APPARATUS 



Motor secre- 
tory, sensory, 
neuroses 



Motor neuroses 



Secretory neu- 
roses 

Sensory neu- 
roses 



Perversions of 
the appetite 



Correction of 
neurotic taint 



part of the physician. To determine definitely that an individual is 
a neuropath is a very precarious undertaking. In all patients who 
are not frank neurasthenics or hysterics the dyspeptic symptoms of 
an incipient tuberculosis or chronic uremia or intestinal toxemia, 
gastric disorders occurring in the presence of adhesions about the 
stomach (and intestine) are consequently often grossly misinter- 
preted. Gastric neuroses pure and simple, I believe to be really 
quite rare, and the diagnosis gastric neurosis or nervous dyspepsia 
is often merely a cloak for ignorance or carelessness. 

Neurotic disorders of the stomach may affect either the motor, 
the secretory or the sensory apparatus of the organ, including the 
sensation of appetite. For the sake of clearness neurotic disturbances 
affecting these different spheres may be discussed separately. It 
is important to realize, however, that perversions of several func- 
tions are, as a rule, associated, that in most cases perversion of single 
functions alternate. This alternation of functional disorders about 
the motor, secretory and sensory apparatus of the stomach, as well 
as the fact that the subjective distress of the patient is, as a rule, out 
of proportion to the severity of the functional disorder that is ob- 
jectively determinable, may be considered to some extent character- 
istic of all gastric neuroses. 

Chief among the motor neuroses are spasm and insufficiency of 
the cardia or the pylorus, hypermotility and peristaltic unrest of 
the stomach, nervous vomiting, nervous belching and gastric atony ; 
among the secretory neuroses hypersecretion and hyperchlorhydria, 
hyposecretion and nervous achylia gastrica ; among the sensory neu- 
roses, gastric hyperesthesia, gastralgia and, in a broader sense, ner- 
vous dyspepsia, so-called ; in the latter condition no motor or secre- 
tory perversions of the stomach are discoverable, but the patients 
complain merely of a great variety of disagreeable subjective sensa- 
tions during and after eating. Perversions of the appetite, finally, 
manifesting themselves as anorexia, akoria and bulimia may also be 
included under the category of sensory neuroses. 

The treatment of all these forms of gastric neuroses con- 
sists primarily and chiefly in correcting the underlying neuropathic 
taint, that is, in restoring normal tone, normal equilibrium to the 
nervous system at large, in re-establishing central autonomy, if it 
is lost ; and in addition any lesion that may be considered a cause for 
reflex irritation of the gastric nerves either in the stomach or in 
other organs (see above) must be sought for and, if possible, re- 
moved. 

The methods at our disposal for curing the neuropathic taint 
are largely psychical and physical. The element of suggestion, 
education and moral suasion enters largely into this treatment: 
while rest, hydrotherapy, the selection of a proper climate and 



DISEASES OF THE DIGESTIVE APPARATUS 561 

resort, massage and, to some extent, electricity are all important 
adjuvants to the treatment. Medicines play a very subordinate 
role. 

In addition certain special methods of treatment may have 
to be instituted that are intended to relieve certain symptoms. 

In order to avoid endless reiteration, the general treatment of the Methods for 
neurotic individual that is indicated in all forms of gastric neu- neurotic in- 
rosis may be discussed first, and the special treatment that is use- dividual 
ful in the different gastric neuroses, later, under separate headings. 

Most cases of gastric neurosis do best, by far, when treated Institution and 
either in an institution or at a resort. In the latter case the good ™*^j} treat " 
effects result from a change of scene, from temporary freedom from 
worry, excitement and business cares and the attendance of skill- 
ful medical men who are specialists in the treatment of these cases, 
because they see so many of them. The feeling, moreover, that 
something definite is being done exercises both a restful effect on 
irritable nerves and, at the same time, a strongly suggestive effect, 
the value of which, in these patients, cannot be overestimated. In 
most resorts, moreover, and this applies also to sanitaria, the various 
hydrotherapeutic and electric treatments, massage and proper diet- 
etic measures can all be carried out much better than at home. 

If the patient cannot or will not enter a sanitarium or go to Simple hydro- 
some resort where good institutional facilities are available, the f ol- home 
lowing simple hydrotherapeutic measures, which can be pursued at 
home, may be of considerable benefit : 

Simplest of all is immersion in a bath of about 95° F. The Hot baths 
patient should remain perfectly still in the water for about five 
minutes. The temperature of the water slightly below the body 
temperature exercises a distinctly soothing influence. After the 
bath the patient should be dried with a rough towel and the sur- 
faces of the body rubbed with alcohol. The patient should then 
be put to bed between woolen blankets and should lie there for an 
hour or two. This treatment may be applied every day either early 
in the morning or late at night before retiring. 

Or the patient may be wrapped in a cloth wrung out of cool Wet, cool pack 
water of room temperature and the surfaces of the body energeti- 
cally slapped and kneaded through the wet sheet. After the treat- 
ment the patient's body should again be rubbed dry with a rough 
towel, treated with alcohol, after which he is put to bed between 
woolen blankets as above. Or a large Priessnitz compress may be Priessnitz com 
applied as follows: The patient is wrapped in a sheet wrung out P resses 
of water of body temperature, the wet sheet is covered with a dry 
sheet and a flannel blanket. In this compress the patient remains 
for one or two hours by which time slow evaporation of water has 
occurred and the first sheet will usually be found to be perfectly 



5G2 



DISEASES OF THE DIGESTIVE APPARATUS 



Spinal spong- 
ing 



dry. The patient is then given a massage with cocoa butter and 
again kept in bed for an hour or two between woolen blankets. 

Half baths A very useful measure, finally, are half baths. The patient 

should sit down in a bath tub containing water of 80° to 90°. 
The water should reach to the umbilicus. An attendant pours 
water of the same temperature as the bath water over the back and 
shoulders of the patient; and at the same time he energetically rubs 
the back and arms, while the patient himself rubs his chest and 
sides. The temperature of the water that is poured over the patient 
may be gradually cooled off. This half bath may to advantage be 
followed by a spray douche, the temperature of which is gradually 
cooled. The patient is then rubbed dry with a rough towel and the 
surface of the body treated with alcohol and the patient put to 
bed between blankets as above. 

A very simple measure that the patient can carry out himself 
is to fill two basins with water, the one with water of about 100°, 
the other with cold water. Into each basin a large sponge is placed. 
The patient sits on the edge of the bath tub and alternately places 
the sponge filled with hot and cold water on the nape of the neck 
and squeezes it out so that the water runs down the back into 
the bath tub. Hot and cold water are, in this way, alternately ap- 
plied about ten times. The patient then rubs his back thoroughly 
with a Turkish towel until a glow is felt. 

In institutions many other hydrotherapeutic means can be em- 
ployed that require special facilities so that they need not be de- 
scribed in this place. 

Massage Massage should be performed only by an expert and it is un- 

necessary to describe the technique in this volume. The effect of 
general massage is soothing to the whole nervous apparatus and 
when combined with rest is one of the most efficient means to 
quiet hyperirritable nerves, to correct irritable weakness of the 
nervous system at large or of certain nervous areas. 

Faradization The soothing effect of massage can be enforced by general farad- 

ization, by the faradic bath or by combining massage with the full 
or half bath or the application of large Priessnitz compresses. The 
best time for administering massage, in most cases, is either early 
in the morning or in the evening before retiring. 
Mitchell Many patients suffering from gastric neuroses of various organs 

do very well under a Weir Mitchell fattening cure. This consists 
largely in over-feeding the patient with a nutritious, assimilable 
diet administered at frequent intervals. In order to be properly 
carried out the patient should be sent to an institution where he 
can be isolated and where, above all, he is removed from sympa- 
thetic friends and relatives; where absolute rest can be enforced, 
and massage and hydrotherapeutic means can be scientifically ad- 



Weir 
cure 



DISEASES OF THE DIGESTIVE APPAKATUS 563 

ministered. In addition, the suggestive effect of such a treat- 
ment should never be underestimated. The personality of the 
physician and of the attendants in an institution and, in many 
cases, firmness to the verge of severity, are very important elements 
in the treatment. 

An exclusive milk diet is not only unnecessar}^, but may even Dangers of ex- 
become harmful, because most cases soon acquire a violent distaste f e e|\ng mi 
to this monotonous feeding; because the ingestion of such large 
quantities of liquid may be detrimental in certain forms of gastric 
neurosis ; and because an exclusive milk diet generally leads to very 
obstinate constipation. It is impossible to designate a diet that ap- 
plies to all cases. It is necessary, generally, to individualize and to 
arrange a dietary somewhat according to the neurosis that the pat- 
ient is suffering from. Broadly speaking, fats and carbohydrates Proper diet 
should predominate and only enough albumen should be given to 
satisfy the nitrogen requirements of the patient. 

The appearance of dyspeptic symptoms does not necessitate dis- 
continuing the treatment, especially if they appear on the first day 
or two, for they usually disappear if the treatment is carried out 
for a few days consecutively. 

The application of heat to the epigastrium before each meal Heat to the 
and during the meal, sometimes continuously, often prevents or e P l &as tnum 
stops disagreeable subjective symptoms about the stomach. The con- 
stipation, that not uncommonly supervenes, is best counteracted by Constipation 
increasing the ration of fruit sauces, fresh vegetables and fats or 
by adding bran with some ceral, cream and sugar to the diet. 
In most cases it will be necessary in addition to give soap-suds ene- 
mata every few days, which may be medicated with a little glycerin 
or, if there is much flatulency, with a few drops of turpentine. 
A little rhubarb or cascara every day can do no harm. The ad- 
ministration of large doses of calomel, which for a long time con- 
stituted a popular routine measure in instituting a Weir Mitchell 
treatment is to be condemned as unnecessary and, in some cases, 
directly harmful. 

The following dietetic schedule approximately illustrates the 
character of the diet that the patient should receive when under- 
going a Weir Mitchell fattening cure: 

First meal. 7 a. m. 250 cc. of milk-cream mixture* or of Diet schedule 
>ocoa made with equal parts of milk and water, three crackers. 

Second meal. 9 a. m. A cup of beef, mutton or chicken broth, 
twenty-five grammes of scraped beef with butter and salt, two 
pieces of toast with plenty of butter. 

Third meal. 11 a. m. 200 cc. of egg-nog, two pieces of zwie- 
back with butter. 



♦Two-thirds milk; one- third cream; a teaspoonful of lime water. 



564 



DISEASES OF THE DIGESTIVE APPARATUS 



Exercise 



Fourth meal. 1 a. m. A cup of broth with rice or barley, 
50 to 60 grammes of roast, stewed or boiled meat, poultry or fish, 
two baked or boiled potatoes or their equivalent in mashed pota- 
toes, a dish of some stewed vegetable, a large saucer of apple sauce 
or preserves. 

Fifth meal. 3 p. m. A glass of egg-nog with two crackers. 

Sixth meal. 6 p. m. Twenty to thirty grammes of cold meat 
or poultry, two slices of toast and butter. 

Seventh meal. 8 p. m. 200 cc. of milk-cream mixture, two 
crackers. 

Eighth meal. 10 a. m. A glass of egg-nog with two teaspoons- 
ful of brandy and two crackers. 

Many patients assert that they cannot take this quantity of 
food. If strenuous objections on the part of the patient are en- 
countered, they may have to be fed by means of a nasal catheter. 
If artificial feeding of this kind must be resorted to for the first 
few days, then, of course, a liquid diet must be given. A little 
firmness on the part of the physician, however, will usually suc- 
ceed in overcoming the objections of the patient. 

After two or three weeks of this treatment the patients usually 
fare better if they are allowed a little exercise, and can go out into 
the fresh air for an hour or so once or twice a day. The duration of 
this Weir Mitchell fattening and rest cure should vary from three 
to six weeks according to the improvement manifested in the pati- 
ent's condition. 



MOTOR NEUROSES. 



Hypermotility 
and peristaltic 
unrest 



Spasm of the 
cardia 



Hypermotility of the stomach and peristaltic unrest of purely 
nervous origin are rare. These motor manifestations may be con- 
sidered as a spasm of the whole gastric musculature. Aside from 
treatment directed against the underlying neurosis, all irritation of 
the gastric mucosa by coarse and indigestible foods, by very hot or 
very cold, spiced or alcoholic articles, should be carefully avoided. 
The diet should be bland and non-irritating and should not dis- 
tend the stomach by its bulk or by the formation of gases. The 
use of sedatives or narcotics, bromides, opiates, belladonna, atropine 
or hyoscyamus will rarely become necessary. 

Spasm of the cardia is also rarely a primary neurosis, but gen- 
erally accompanies various organic disorders of the esophagus, the 
cardiac orifice or the cavity of the stomach. It may, therefore, be 
merely a symptom of a variety of causes that must be carefully 
sought for and removed as described in other sections. It may, 
however, be a primary neurosis and if this is the case it is usually 



DISEASES OF THE DIGESTIVE APPARATUS 565 

associated with hyperirritability of the esophagus. Here, again, 
therefore, the ingestion of food and drink that may irritate the 
esophageal muscosa, either mechanically, chemically or thermi- 
cally, must be avoided as a prophylactic measure. The insertion 
of sounds of gradually increasing calibre and leaving these sounds 
in place is the best method of treating cardiospasm, provided no 
organic lesion about the cardia of an ulcerative character contra- 
indicates the use of bougies. In extreme cases the above mentioned 
sedatives and narcotics administered hypodermically or in supposi- 
tory, combined with complete abstinence from food for several days 
and rectal alimentation, may become necessary. 

Spasm of the pylorus is almost always due to some intragastric Spasm of the 
irritation. The neurotic character of pyloric spasm is problematical P vl °nis 
in any case. If no determinable cause like ulcer, hyper chlorhydria 
or some mechanical lesion about the pylorus is discoverable, and if 
symptoms of pyloric spasm (pain, increased gastric peristalsis, 
vomiting) appear when food that is irritating by its texture, tem- 
perature or mechanical constitution enters the stomach, then the 
existence of an increased pyloric sphincter reflex, i. e., pyloric 
spasm of neurotic origin, may be suspected. In an overwhelming 
majority of cases, however, some organic disorder or secretory per- 
version about the stomach will be found. 

The treatment consists in the removal of any mechanical or 
organic condition about the stomach that may be incriminated with 
causing the spasm, and in correcting the underlying neurosis, in the 
neurotic type. The treatment in all cases should concern itself 
with removing or counteracting any accompanying hyperchlorhy- 
dria. In extreme instances, again, sedatives and narcotics may 
have to be used. The bougie treatment of pyloric spasm has been 
variously attempted, but this mechanical means of treatment is 
manifestly a procedure accompanied by such immense technical 
difficulties and uncertainties that it is hardly to be considered 
practical. 

Nervous belching is in most cases an hysterical phenomenon Nervous belch- 
due to the swallowing of air. The treatment is largely psychic, s 
i. e., educatinary. Very often persistent attacks of nervous eructa- 
tion can be stopped, like hiccup, by suddenly frightening the pati- 
ent. In other cases the patient should be ordered to breathe with 
the mouth open for half an hour two or three times a day. This ex- 
ercises a pronounced psychic effect and, at at same time, prevents 
the patient from swallowing the air, at least during the periods of 
mouth-breathing, and hence prevents eructation. If there is much 
distention of the stomach with air (pneumatosis), passing the stom- 
ach tube brings prompt relief. If there is any doubt in regard to 



566 



DISEASES OF THE DIGESTIVE APPARATUS 



Diet 



Nervous 
king 



vom- 



Seasickness 



the character of the belching, a fermentation test with the stomach 
contents will quickly tell the tale. 

Aside from the suggestive treatment and general measures 
directed towards the neurasthenic and hysteric state, bromides, 
belladonna and atropine, and in some cases, especially in pro- 
nounced pneumatosis, the hypodermic use of morphine, may be- 
come necessary. Silver iodatus, in doses of a sixth of a grain 
(0.01) after eating, and strychnine in one-thirtieth to a sixtieth 
of a grain doses also after eating, are recommended. 

The diet should, of course, contain no carbonated beverages and 
the minimum of articles that can undergo gaseous fermentation 
in the stomach should be allowed; for the development of gas 
in the stomach by producing real eructations may by suggestion 
start an attack of nervous belching. 

Nervous vomiting, in a broad sense, includes vomiting orig- 
inating from reflex irritation from the sexual sphere, from float- 
ing kidney, from diseases of the brain and cord, from colic in 
the liver or the kidneys, from peritoneal irritation and from 
the pregnant uterus. Here the treatment of the underlying cause 
and the correction of a nervous predisposition, that must be as- 
sumed to exist in all cases becomes necessary. In every case of 
nervous vomiting, the gastric irritability should be reduced. In 
severe cases the patient should remain in bed, should abstain alto- 
gether from food for a few days and should be allowed to swallow 
only teaspoonful doses of ice cold drinks like milk, tea, cham- 
pagne, or ice pills. No definite dietetic regulations can be formu- 
lated in the neurotic type of vomiting. Of drugs morphine, code- 
ine and belladonna hypodermically or in suppository are the best. 
Morphine may be given in doses of an eighth of a grain in combin- 
ation with a two-hundredth of a grain of atropin hypodermically, 
once or twice a day ; codeine or codeine phosphate in doses of half 
a grain (0.03) hypodermically, once or twice a day; or opium and 
belladonna in suppositories containing half a grain (0.03 gm.) each 
of the extract of opium and the extract of belladonna and ad- 
ministered once or twice a day. 

Seasickness is persumably a gastric neurosis occurring paroxys- 
mally; hence treatment should be directed towards calming the 
central nervous system. A very useful method of procedure is the 
following : — 

Moderate eating for two days prior to embarcation, with thor- 
ough evacuation of the bowels by means of a brisk purge. On go- 
ing on board the following prescription: 



DISEASES OF THE DIGESTIVE APPARATUS 50' 



I* 










Calcium carbonate 








3.0 


Magnesia usta 








2.0 


Magist. bismuthi 








0.5 


M. Sig. Suspend in 50 


cc. of 1 


water and take to- 


gether with a teaspoonful 


of 


the 


following 


mixture : 










3 










Picrotoxin 








0.05 


Morphine mur. 








0.05 


Atropine sulph. 








0.01 


M. Sig. A teaspoonful 


in water. 







The picrotoxin prescription can be taken repeatedly during Picrotoxin 
the day in teaspoonful doses together with 10 to 15 grains of car- 
bonate of calcium. At the same time the food intake should be 
maintained at a minimum and the bowels kept thoroughly cleaned 
out. 

Other remedies that are occasionally useful are chloroform Chloroform 
given in the dose of three to five drops on sugar or in teaspoonful 
doses of ice cold chloroform water; menthol in ethereal solution (1 
to 10) in the dose of five to ten drops three times a day; chloral Chloral 
hydrate in a solution of one part to ten parts of water may be given 
in fifteen drop doses in a teaspoonful of ice water every two or 
three hours. Bromides and chloral nitrate, ten to twenty grains 
each, may be given by rectum. 

Lavage is generally superfluous in these cases. Douching with Lavage 
silver nitrate in 1 :1000 solution, or simple irrigation of the stom- 
ach, is occasionally useful. In employing lavage or douching the 
suggestive effect exercised by passing the stomach tube is generally 
more helpful than the procedures themselves. 

Pyloric insufficiency is usually due to mechanical causes oper- Pyloric insuf 
ating either to interfere with the closure of the pyloric sphinc- ficienc y 
ter (cicatrization, ulceration, etc.) or leading to abnormal stretch- 
ing of the pyloric ring. Nervous cases of pyloric insufficiency due 
to paralysis of the motor nerves supplying the sphincter are seen 
in hysteria and in certain diseases of the spinal cord. The neurotic 
form is exceedingly rare and should only be diagnosed if the or- 
ganic form can be definitely excluded. In the organic variety the 
treatment is exclusively causal in the nervous form, it is directed 
towards correcting the general neuropathic taint, and local treat- 
ment has no effect. 

Eegurgitation and rumination (insufficiency of the cardia) an( f r^iina- 
should be treated chiefly by education and suggestion and by mea- tion (insuffi- 
sures directed towards correcting the underlying neurosis. The Jjardia) ° ° 



568 DISEASES OF THE DIGESTIVE APPARATUS 

patients should be told to chew their food thoroughly and to eat 
slowly. Inasmuch as the disease is frequently produced in friends 
or schoolmates of the patients by imitation, isolation of the patient 
in an institution, aside from facilitating the treatment of the 
patient himself, is often effective in preventing the spread of the 
disease in persons closely associated with the sufferer. 
Neurotic atony Gastric atony has already been discussed in a previous sec- 

tion (see index). The treatment of the neurotic variety differs in 
no way from that produced by organic or mechanical causes. 



SECRETORY NEUROSES. 

Neurotic secre- rp-^g secre tory neuroses of the stomach that manifest them- 

sions selves as hypersecretion and hyperchlorhydria, as hypochlorhydria 

and achylia, have already been discussed in special sections, so that 
it is needless to repeat here what has been said. If one is dealing 
with a purely neurotic form of secretory neurosis, then, in addition 
to the dietetic, mechanical and medicinal means that have been 
recommended for the treatment of these conditions, recourse must 
be had to the use of the general hydrotherapeutic, and electrothera- 
peutic means and all the other measures that are used in the treat- 
ment of neuropathic individuals. In the same sense organic lesions 
in and around the stomach or in remote organs that may by re- 
flex irritation cause functional perversions of the gastric secretion, 
must be sought for and corrected, if possible. 

Many patients in whom gastric analysis does not reveal the 
existence of hyperacidity but in whom hydrochloric acid is either 
Normal or even subnormal, occasionally present typical symptoms 
of gactric hyperacidity, including pain about the heart after eat- 
ing, that is promptly relieved by the administration of an alkali. 
The hyperesthesia of the gastric mucosa that produces these 
symptoms incidentally also leads to chronic malnutrition, anemia, 
spastic constipation. 

In these cases the use of antacids should be carefully regulated 
and only so much magnesium carbonate or sodium bicarbonate ad- 
ministered as to neutralize the gastric hydrochloric acid at a time 
when the height of digestion is passed. If the gastric acidity is 
subnormal, then antacids are of very little value and sedative reme- 
dies like valerian, bromides, asafetida are much more useful, especi- 
ally when combined with the hydrotherapeutic and counter-irrita- 
tive messares discussed in another place. 



DISEASES OF THE DIGESTIVE APPARATUS 569 

SENSORY NEUROSES. 

Gastric hyperesthesia may occur as an independent affection, Gastric hyper- 
but it is usually found attended by secretory perversions of the 
stomach. It is indicated by a variety of abnormal sensations 
about the stomach, as fullness, tension or burning, or by severe 
paroxysms of pain, i. e., gastralgia proper. Gastralgia occurs in Gastralgia 
many organic diseases of the stomach and also in affections of or- 
gans adjacent to the stomach as, for instance, in the presence of ad- 
hesions, aneurism of the abdominal aorta, aortic insuffi- 
ciency, in neuroses of the solar plexus, especially in sexual dis- 
orders, in cord diseases (gastris crises of locomotor ataxia) and in a 
variety of intoxications and infections, in constitutional diseases 
(poisoning with tobacco or lead, in malaria, Addison's disease, 
the uratic diathesis, chlorosis, tuberculosis, etc.). Finally, par- 
oxysms of gastralgia may be a part phenomenon of neurasthenia 
or hysteria. 

Manifestations of gastric hyperesthesia or attacks of gastralgia Causal treat- 
occurring when the stomach is empty are best relieved by the in- ment 
gestion of food. If hyperesthesia or gastralgia are not due to reme- 
diable causes, or if the latter are not discoverable or, again, if 
these symptoms, occurring in a neurotic subject, do not yield to 
the general treatment of the underlying neurosis, then certain 
measures for the s} r mptomatic relief of gastric pain must be em- 
ployed. 

One of the most useful measures is the application of heat to Symptomatic 
the epigastrium, either by means of hot poultices made of oat- treatment 
meal, linseed, or bread, and medicated with a few drops of opium Atrium epl " 
or belladonna tincture; by the use of a Leiter coil (see index) 
through which hot water is flowing, or by means of a so-called Win- 
ternitz compress applied as follows: A wet linen cloth is applied Winternitz 
over the epigastrium; over it is placed a Leiter coil through which com P ress 
flows hot water and over this again another wet sheet; the whole 
is covered with a flannel. By the use of this Winternitz com- 
press a prolonged heat effect and considerable counter-irritation is 
produced. The thermophore, as previously described, is also useful 
for the application of continuous heat to the epigastrium. 

Electrization of the stomach too is of some value in the treat- Electrization of 
ment of hyperesthesia and gastralgia. Either the intraventricular 
or extra -ventricular method may be employed. In the former case 
the anode should be inserted into the stomach through a stomach 
tube, in the latter case the anode should be applied to the epigastric 
region by means of a large plate electrode. The cathode is con- 
nected with a large sponge electrode applied either to the sternum 



570 



DISEASES OF THE DIGESTIVE APPARATUS 



Gastric 
douches 



Morphine 

Chloroform 
Cocaine 

Bromoform 
Antineuralgics 



Atropine 
Methyl bromate 



Nervous dys- 
pepsia 



Alternation of 
diet 



or between the shoulder blades. A weak galvanic current is ap- 
plied for not longer than ten minutes. 

Douching the stomach with chloroform water or with silver 
nitrate solution 1:1,000, or simply with hot plrysiological salt so- 
lution, is a very useful measure, especially in cases that do not yield 
to the simple application of heat to the epigastrium. 

For internal use a variety of remedies can be emploj^ed. 

Lupulin in sensory and in secretory neuroses of the stomach is 
often useful, administered in the dose of 0.3 g. in a gelatine cap- 
sule from one to two hours before meals, three times a day. 

Morphine in the dose of one-eighth to one-fourth grain, or 
codeine phosphate in the dose of half a grain, may occasionally 
have to be given hypodermically, or a suppository containing ex- 
tract of opium and belladonna, may be used. A few drops of 
chloroform on ice, or ice cold chloroform water in teaspoonful 
doses, sometimes afford relief. Cocaine is a useful remedy ad- 
ministered by pouring twenty drops of a five per cent, solution 
of cocaine in a third of a glass of water and administering a tea- 
spoonful of this solution every fifteen minutes. Bromoform in 
two or three drop doses on ice, or in teaspoonful of ice water, or 
in a 1 : 1,000 solution, a teaspoonful every two or three hours, may 
also be used. Finally antineuralgic remedies as antipyrin, phe- 
nacetin in five to fifteen grain doses (0.3 to 1 gm.), lactophenin or 
exalgin in eight to fifteen grain doses (0.5 to 1 gm.), or pyramidon 
(especially in tabetic crises) in the dose of fifteen to thirty grains 
(1 to 2 gm.) administered with water two or three times in one 
or two hour intervals, may be employed. 

Atropine methyl bromate is less toxic than the sulphate, par- 
ticularly in its action upon the cardiac and respiratory functions. 
The drug, of course, is principally used in eye work, but has a dis- 
tinct field of application in internal medicine. It is very valuable 
in reducing the lancinating pains of tabes and in neurasthenic and 
hysterical headaches. In nervous hypersecretion and in neuralgic 
pains in different parts of the hodj, it is also effective. It can 
either be administered in powder form or in solution in the dose 
of from 1 to 3 mg. Its action is enforced by combination with 
other anti-neuralgic and anti-rheumatic drugs. 

In the treatment of "nervous dyspepsia" suggestion and the 
appropriate hydrotherapeutic and electrotherapeutic measures, mas- 
sage or a Weir Mitchell fattening — rest cure, as described above, are 
usually sufficient to bring about a cure. Any reflex disorders should 
be removed. The patients should be protected from care, worry and 
excitement and any psychic or emotional shock. No fixed rules in 
regard to the diet can be formulated. Some patients do exceeding- 
ly well on a Weir Mitchell fattening cure, others on a starvation 



DISEASES OF THE DIGESTIVE APPARATUS 571 

plan, some thrive on an exclusively vegetable diet, others on milk 
feeding, still others on a mixed general diet. Very often a change 
from one diet to another acts beneficially for a time ; and it is gen- 
erally a good plan, partially, it must be confessed, on account of the 
suggestive effect produced, to alternate with the diet, feeding the 
patient for a time on vegetables exclusively, letting him hunger 
for a week, and giving him rectal feeding for another period, then 
allowing a general diet for a time or a milk diet, or instituting a 
Weir Mitchell cure. 

A starvation plan with rectal feeding should always be given a Starvation 
trial. Within certain limitations the caprices of the patient should p an 
be considered and if a general diet is permitted, great care should 
be exercised to render the food palatable and tempting to the pa- 
tient. In no disease are the arbitrary methods of the doctrinaire 
more dangerous than in this disorder. Care should always be ex- 
ercised not to administer any really indigestible foods that might 
produce genuine dyspepsia; for the latter would produce a bad 
moral effect upon the patient who cannot distinguish between a 
real and a nervous dyspepsia. That every endeavor should be put 
forward in all these methods of feeding to maintain full nutrition, 
excepting possibly for short periods of time, need hardly be em- 
phasized. 

Smoking is, as a rule, to be forbidden. Alcohol in the form of Smoking 
dilute whisky or brandy, Claret or Moselle as a table beverage, Liquor 
may be used in moderate quantities. 

Eest after eating is also a useful measure for reasons that have R e ?t after 
been discussed above. Lavage and douching are rarely indicated in 
nervous dyspepsia and whatever good effects may be witnessed from 
the use of these measures must be attributed largely to their sug- 
gestive influence. Medicines play a very subordinate role in the 
treatment of nervous dyspepsia. Stomachics and hydrochloric 
acid given as before advised can do no harm. Any accompanying 
constipation or diarrhea should be combated chiefly by dietetic 
and mechanical means and by medicines only in extreme cases. 



CHAPTER XL 

DISEASES OF THE INTESTINE AND PERITONEUM. 

ACUTE INTESTINAL CATARRH. 

Most cases of intestinal catarrh are due to irritation of the Causal treat- 
bowel wall by toxic or infectious agencies. The latter may be in- ment 
gested with the food and irritate the bowel directly from within, or 
they may be borne to the intestinal wall through the blood. Causal 
treatment must attempt, therefore, above all things, to promptly 
rid the organism of these toxic bodies. In the case of the blood- 
borne toxins this is not always an easy task. In some 
instances, however, as in malarial toxemia where we possess spe- Malarial di- 
cific antimalarial treatment, this is possible. In catarrh of the arrh ea 
bowel occurring in the course of other infections and intoxica- 
tions and due to the circulation of bacterial toxins or of meta- 
bolic poisons (e. g., uremic diarrhea) through the bowel Uremic di- 
wall with irritation of the bowel mucosa, very little can be done arrhea 
towards attacking the primary cause of the intestinal disorder. 

Acute intestinal catarrh due to the ingestion of toxic mate- 
rial is much more amenable to causal treatment. If the poison 
is one that is foreign to normal food and if its character is 
known, the appropriate antidote should, self-evidently, be ad- 
ministered at once, and removal of the offending material 
promoted by lavage of the stomach and free evacuation of the bowel 
contents. 

In all forms of food poisoning, whether due to mechanical 
irritation of the bowel wall by coarse foods or compacted feces in 
chronic constipation, or to chemical irritation from poisons con- 
tained in spoiled foods or formed from the gastro-enteric con- 
tents by abnormal bacteria vegetating in the bowel, prompt empty- 
ing of the intestine and evacuation of the noxious agency is the 
first rule. 

The two principal eliminants that should be employed in these Eliminants 
cases are calomel and castor oil. Drastic purgatives and salines 
should not be used in acute catarrh of the bowel, as they irritate 
the inflamed mucosa still more. 

Calomel is best given in one large dose of three to five grains Calomel 
(0.2 to 0.3 gm.). Smaller doses are more apt to irritate the 



574 



DISEASES OF THE INTESTINE AND PERITONEUM 



Castor oil 



Bowel irriga- 
tion 



Mode of insert- 
ing rectal tube 



Irrigating 
fluids 



bowel wall without exercising so pronounced a purgative effect. 
Castor oil should be given in the dose of half an ounce to an 
ounce (one to two teaspoonfuls to an infant or a little child) 
either in gelatin capsules or in a small glass of beer or in beef 
tea; or the oil may be mixed with peppermint water, or with 
milk flavored with peppermint oil and rapidly gulped down; or 
it may be poured into a wine glass and an equal quantity of sherry 
or port wine superimposed and the whole taken in one swallow. 
In order to mitigate the severe griping and colic that frequently 
follows the use of castor oil, a few drops of tincture of opium, or a 
drop of cinnamon oil, may to advantage be added to the dose. 

Eemoval of the offending material from the bowel should also 
always be promoted by irrigation of the large intestine. The rectal 
catheter used for colonic flushings should be about thirty to forty 
centimeters long and should have a lumen of about one centimeter. 
Before inserting it all the air should be driven out of the tube 
by filling it with water from the funnel or irrigating bag it is 
connected with. The tube should always be well lubricated 
with oil or with vaseline and should be inserted gently and care- 
fully with a slow rotary movement until fifteen to thirty centi- 
meters have entered the bowel. If the tube catches it should not 
be pushed in forcibly, but slowly withdrawn a little and rein- 
serted. The patient should be placed either on the left side with 
the right leg drawn up and the hips elevated by one or two pil- 
lows, or in the knee-chest position, or in the dorsal position 
with raised hips. As soon as the tube is in place the irrigating 
fluid is allowed to flow in very slowly and under low pressure, 
i. e., from a height not to exceed two feet. Fully ten to fifteen 
minutes should be consumed in injecting two liters; in this way 
retention of the irrigating fluid is made much easier and less 
pain and discomfort are produced. If the water stops flowing 
altogether, this may be due to the impaction of a fecal plug in 
the opening of the tube or to knuckling of the catheter; in either 
case the tube should be withdrawn a few inches. If the flow does 
not start again, then the catheter must be entirely withdrawn, 
cleansed and reinserted. 

For the purpose of colonic flushing, pure water, normal salt 
solution 6 to 8 to 1,000, soapy water or water medicated with a 
tablespoonful of glycerin to the quart, or with certain laxative, dis- 
infectant or astringent remedies, may be used. In some cases 
in which there is much impaction of hard fecal material in the 
lower bowel, a preliminary injection of six to eight ounces of 
olive oil may be practised in order to promote softening of the 
contents of the large intestine. 



DISEASES OF THE INTESTINE AND PERITONEUM 575 

I 

After removal of the poisonous and irritating bowel contents Rest of the 
by calomel or castor oil and by rectal irrigation, the next most we 
important rule is to place the bowel wall at rest, to spare the intes- 
tinal mucosa in order to allow the undisturbed re-establishment of 
normal conditions. 

In order to do this, the following dietetic rules should be ob- Diet 
served: During the first twenty-four hours complete abstinence Abstinence 
from food is the best plan, and this treatment can usually be 
carried out without difficulty because the patients spontaneously 
refuse to eat. The severe thirst that sufferers from acute intes- Thirst 
tinal catarrh usually experience during the first twenty-four 
hours can be relieved by small swallows of sterile water or tea, 
or by allowing the patient to dissolve pieces of ice in the mouth. 
Chewing gum is also an efficient means to relieve the sensation 
of thirst. Inasmuch as sufficient liquid to satisfy the water re- Water by 
quirements of the organism cannot and should not be supplied rectum 
in this way, irrigation of the colon with normal salt solution may 
aid in supplying this deficit. 

In very mild cases a little gruel or soup made of oatmeal, rice Gruels 
or barley flour, sago, arrow-root or tapioca and water, carefully 
strained and flavored with a little salt or a little meat extract, 
may be allowed on the first day, in tablespoonful doses. In all 
cases this diet is permissible on the second day. In addition, Albumen water 
the patients may receive a little albumen water or egg-nog made 
of the white alone; a little Claret or brandy diluted with boiled 
water, or weak tea should constitute the chief beverages on the 
second day. 

Milk is well borne by some subjects and not at all by others. Milk 
It should never be given raw in cases of acute intestinal catarrh, 
but only boiled or carefully sterilized, never cold and never too 
hot, but only lukewarm in small quantities at a time and best 
with a tablespoonful of lime water or a teaspoonful or two of 
brandy to the tumblerful. If milk increases the diarrhea, then 
buttermilk or kumyss or kephyr, administered in tablespoon 
doses, may be tried. The nourishing character of these milk 
preparations renders them very useful provided they can be 
borne. 

On the third day it is permissible to add a little toast, zwie- Diet after the 
back or crackers to the above dietary. In addition, meat broths * ir ay 
with an egg, or some cocoa may be given. This simple, semi- 
liquid diet should be continued until the diarrheic discharges have 
stopped ; then a little raw, scraped meat or broiled beef or mutton 
may be given, also squab or some white meat of chicken, meat jelly, 
gelatinous food, a little rice or tapioca, some vegetable purees and 
mashed potatoes. 



576 



DISEASES OE THE INTESTINE AND PERITONEUM 



Food to be 
avoided 



Drugs 



Intestinal anti- 
septics 



Calomel 



Dilute HC1 

Resorcin 

Menthol 

Creosote 

Salicylic acid 

Salol 

Beta-naphthol 

Benzo-naphthol 



Danger of me- 
tallic anti- 
septics 



Ichthoform 



Administration 
in keratinized 
pills or glutoid 
capsules 



Astringents 



All fried foods, foods prepared with much fat, fresh fruit, 
acid or spiced foods, very hot or very cold foods should be avoided 
for some days after the diarrhea has stopped. 

Special medicines are rarely required in the treatment of 
acute intestinal catarrh. Certain of the group of intestinal anti- 
septics may be employed to hold the development of the bacterial 
flora in the intestine in check. The use of some of the intestinal 
antiseptics, sodium glycocholate, organic peroxides and sulpho- 
carbolates have already been fully discussed in the Section on 
Bright's Disease. Other intestinal antiseptics that can be used 
are calomel in very small doses, i. e., a twentieth to a tenth of a 
grain, two or three times a day. In this dose calomel does not irri- 
tate the bowel wall nor does it pnrge, but merely inhibits bacterial 
life. Dilute hydrochloric acid in five to ten drop doses may be 
given for a similar purpose. The following remedies may all be 
tried : Eesorcin in five per cent, solution, three to five teaspoon- 
fuls a day; menthol, two grains (0.12 gm.) two or three times 
a day; creosote, one to three drops (0.06 to 0.18 gm.) 
in brandy or wine several times a day or in olive oil, in 
gelatin capsules or in solution with some simple synrp; salicylic 
acid, five to thirty grains (0.3 to 2 gm.) in capsule or 
in solution; salol, in the same dose; naphthaline, one to 
five grains (0.06 to 0.3 gm.) ; beta-naphthol, three to ten grains 
(0.2 to 0.6 gm.); benzo-naphthol, five to ten grains (0.3 to 0.6 
gm.). 

In acute intestinal catarrh particular care should be exer- 
cised to avoid the administration of intestinal antiseptics that 
are irritating to the bowel wall ; thus most of the metallic salts 
with antiseptic properties, with the exception of calomel given 
as above, should be eschewed. A very useful preparation is ichtho- 
form, a combination of formaldehyde and ichthyol, which splits 
off formaldehyde in the intestine. It should be given in two to 
three grain doses, twice or three times a day. 

Many of the above intestinal antiseptics can to advantage be 
given in keratinized pills or glutoid (Sahli) capsules, i. e., cap- 
sules, made of gelatin hardened with formaldehyde or, also, in 
pills coated with salol; in this way they pass through the stom- 
ach unchanged and exercise their full effect in the bowel. 

Astringent remedies are not often indicated in acute catarrh 
of the bowel. They should never be used during the first two 
or three days. If the diarrhea persists for many days uninfluenced 
by other measures, then some of the astringent group of medicines 
may have to be employed. They will be discussed in full in the 
Section on Chronic Intestinal Catarrh, 



DISEASES OF THE INTESTINE AND PERITONEUM 577 

Narcotics are generally superfluous. If there is much pain Narcotics 
and if the diarrhea persists, despite the complete evacuation of 
the irritating bowel contents by calomel or castor oil and by in- 
testinal irrigation, then opium or morphine may have to be re- 
sorted to. Opiates stimulate the nerves that inhibit intestinal 
peristalsis, i. e., check the latter. They also render the sensory 
nerve endings in the bowel less sensitive to irritation by bowel 
poisons and thereby also aid in arresting peristalsis. The best 
mode of administering opiates is either in suppository with bella- 
donna (of each extract % g ra i n ), or in the dose of fifteen to 
twenty drops of the tincture of opium as an enema in starch 
water (two teaspoonfuls of starch flour in eight ounces of wa- 
ter). If there is much gastric or rectal irritation, so that the ad- 
ministration of opium by mouth or rectum is disagreeable then 
morphine in one-sixteenth or one-eighth grain doses may be given 
hypodermically. 

The constipation following the use of opiates, as well as the Constipation 
constipation that generally follows the diarrhea in acute intes- following opi- 
final catarrh, calls for no special treatment. It may be allowed 
to persist for several days after the diarrhea is checked and 
should then, if necessary, be relieved by enemas and by the proper 
diet (see Section on Constipation). 

Heat applied to the abdomen in the form of hot water bags, Heat 
poultices, hot compresses or dry, hot cloths is always grateful to 
those afflicted with acute intestinal catarrh and materially aids in 
reducing the colicky pain. If there is much flatulency, turpentine 
stupes (cloths wrung out of hot water medicated with two or three Stupes 
drops of oil of turpentine) or enemata medicated with two or 
three drops of turpentine or with carminative remedies are useful 
(see also Section on Meteorism). 

If there is fever rest in bed should be enforced. Cases of acute Fever 
intestinal catarrh that manifestly follow exposure to cold, should 
be given a hot bath, wrapped in blankets and allowed to sweat. 
Drop doses of the tincture of aconite repeated four or five times, at 
hour intervals, or a ten grain Dover's powder, given in the begin- 
ning, often aid in shortening the attack. That the other measures 
described for the treatment of acute intestinal catarrh should be 
employed in addition, is self-evident. 

In cases that go into collapse analeptic remedies like cam- Analeptics 
phor, ether or ammonia should be administered. Hot alcoholic 
drinks should be taken, hot water bags or bottles put 
to the feet and legs, the extremities rubbed with rough towels, 
and the patient wrapped in woolen blankets with an ice bag to the 
head. 



578 



DISEASES OF THE INTESTINE AND PERITONEUM 



CHRONIC INTESTINAL CATARRH. 



General indi- 
cations 



Diet 



General char- 
acter of diet 



Forbidden 
foods 



Analysis of 
stools as index 
for the dietary 



In no case of chronic intestinal catarrh is it possible by any 
known means to directly influence the diseased condition of the 
intestinal mucosa. All one can do is to avoid further irritation 
of the inflamed area by the selection of the proper food and by the 
administration of drugs that prevent the formation of irritating- 
products in the bowel and their stagnation in intimate contact 
with the catarrhal lining membrane of the intestine. At the same 
time general hygienic means may be employed intended to im- 
prove the general health and nutrition of the patient and thus en- 
able him to put forward the maximum effort towards restoration 
of tissue integrity. 

The diet, above all, in chronic intestinal catarrh, as in any 
other chronic disorder, should be nutritious enough to satisfy the 
daily caloric requirements of the individual. The ingestion of 
sufficient calories is often a difficult task owing to the existence of 
diarrhea with loss of valuable pabulum in the stools, and also on 
account of the presence of chronic catarrhal changes in the in- 
testinal mucosa which interfere with the proper intestinal diges- 
tion and hence render only part of the ingested food available 
for the nutrition of the patient. 

Generally speaking the diet, aside from being nutritious, should 
also be non-irritating to the bowel wall, i. e., it should contain 
no coarse or indigestible particles, no spices, condiments, no very 
acid, very sweet or very fat foods of any kind. Fruits and salads 
are forbidden. 

In selecting a general dietary from permitted articles, the 
individual likes and dislikes of the patient must be considered. 
In so prolonged a disorder as chronic intestinal catarrh it is 
worse than useless to force the patients to eat articles of food 
that they thoroughly dislike. On the other hand to be too arbi- 
trary in absolutely forbidding small quantities of articles of food 
that theoretically might be harmful, but that the patients crave, 
is also bad practice. The stimulation of the appetite above all is 
an important element in aiding digestion and in maintaining the 
nutrition of the patient. 

The main index, however, that teaches whether or not an arti- 
cle is well borne and properly digested is an analysis of the stools. 
A study of the feces after various "test meals" is of equal im- 
portance here as the analysis of the stomach contents in stomach 
disorders. Whenever an article, that, on theoretical grounds, is 
indicated and permissible, persistently reappears in the stools in a 
semi-digested or undigested form, then its further administration 
becomes worse than useless; for not only does it not contribute to 



DISEASES OF THE INTESTINE AND PERITONEUM 579 

the patient's support, but it positively aggravates the catarrhal 
condition of the intestinal mucosa by its action as a mechanical 
or chemical irritant throughout the length of the intestinal 
canal. 

The following articles, with the above reservations, are the most Useful and per- 
usef ul in chronic intestinal catarrh : All meats of tender varieties, missl e 00 s 
especially white meats, fish and poultry, always finely divided and Meats 
freed from skin and tendon; meat jellies, gelatinous foods, meat 
broths; eggs should be given only soft boiled, scrambled and pre- Eggs 
pared with very little fat. Gruels made with water or milk and Gruels 
tapioca, sago, arrow-root, rice, barley flour, etc., are useful. Milk Milk 
is usually well borne in chronic intestinal catarrh even when 
administered in large quantities, provided it is altogether 
fresh, otherwise it may become troublesome. It is always 
safer to administer it boiled or carefully sterilized than raw. The 
digestibility of milk, as repeatedly stated, may be increased by 
the addition of lime water or of a little brandy. Kephyr, Kephyr 
kumyss and buttermilk are also allowed. The lactic acid con- Kumyss 
tained in these beverages acts, to some extent, as an intestinal Buttermilk 
antiseptic and may be useful on these grounds. Cereals and Cereals and 
bread stuffs, noodles, marconi and other dishes made of flour 
are permissible, provided they are not prepared with too much 
fat. Of breads, sour and coarse kinds should never be 
given, but chiefly dried bread, toast, crackers, zwieback. The 
fat demand may be supplied by fresh butter and cream, and Fa ts 
vegetable oils; meat fats, like lard, suet and bacon are not so well 
borne. 

Of beverages, boiled water, sterile milk, a little dilute Claret Beverages 
or Moselle wine or whisky and water, mineral waters that have 
been shaken in order to cause the evaporation of carbonic acid 
gas, tea and cocoa are all allowable. Beer, champagne, strong 
alcoholic liquors and coffee are to be denied. 

In cases of chronic intestinal catarrh accompanied by very Diet in consti- 
obstinate constipation, a little more of cereals and fats, of fresh P atl0n 
vegetables, even of fruits, may have to be given. In cases, on 
the other hand, that suffer from diarrhea more meat and milk Diet in di- 
and less of the above articles should be administered. arrnea 

Small meals at frequent intervals are always better than large Small meals 
meals. The patients should be instructed to eat very slowly 
and to thoroughly masticate their food. If at all possible they 
should be instructed to lie down or to rest quietly for from half 
an hour to an hour after the main midday and evening meals. 

For the purpose of inhibiting abnormal fermentative processes Drugs 
in the bowel a variety of medicines are used; chief among these 
are tannic acid preparations, especially in that large group of Tannic acid 



580 



DISEASES OF THE INTESTINE AND PERITONEUM 



Tannigen 
Tannalbin 



Catechu 
Rhatany 
Colombo 
Kino 



Bismuth prep- 
arations 



Dermatol 
Xeroform 



Yeast 



cases of chronic intestinal catarrh that suffer from persistent diar- 
rhea. The members of the tannic acid group are credited with 
"astringent" properties. As a matter of fact they aid chiefly by 
stopping putrefaction of bowel contents. The best tannic acid 
preparations in chronic intestinal catarrh are tannigen and tannal- 
bin; for neither of these drugs is attacked by the gastric juice, so 
that the tannin they contain really exercises its full effect upon 
the bowel contents. Tannic acid, itself, and preparations of cat- 
echu, rhatany, Colombo, kino, etc., that all contain some tannic acid, 
may all be used in the diarrhea of chronic intestinal catarrh 
(usually in combination with opium) to check fermentation, but 
they are not without effect on the stomach, and besides, a large 
part of the tannin is absorbed in the stomach and hence does not 
become available for use in the bowel. Tannalbin, however, an 
albumin compound of tannin, containing about five per cent, of 
the latter and rendered resistent to peptic digestion by heating to 
120° C, enters the bowel unchanged and is there split up by 
the alkaline intestinal juices. Tannigen (diacetyl tannic acid) 
possesses similar properties. Each of these remedies should be 
given in ten to thirty grain (0.6 to 2 gm.) doses several times a 
day, in powder form. 

Next in importance to tannic acid preparations in the treat- 
ment of diarrhea due to chronic intestinal catarrh are a variety 
of bismuth preparations. The exact mode of action of bismuth 
in these cases is not altogether understood. It is probable that it 
acts mechanically by forming a coating over the inflamed mucosa 
and thereby protects it against irritating bowel contents. Bis- 
muth, in order to be effective, should be given in large quantities, 
either as the subnitrate or as the subsalicylate in doses of fifteen 
to thirty grains (1 to 2 gm.) in powder, three or four times a 
day. Both these bismuth preparations can, to advantage, be 
given together with a little extract of opium. Two other good 
preparations of bismuth are dermatol given in the dose of one 
and a half to three grains (0.1 to 0.2 gm.) and xeroform* in the 
dose of fifteen to sixty grains (1 to 4 gm.). Both of these prep- 
arations are split up in the bowel — into bismuth and tannic acid, 
in the case of dermatol; or an aromatic antiseptic radical in the 
case of xeroform, so that they combine the mechanical action of 
bismuth with the antiseptic action of the tannin and phenyl deriva- 
tive they incorporate. 

An exceedingly useful preparation in gastro-enteritis, particu- 
larly in children, is yeast. Ordinary brewer's yeast may be ad- 



*To the same group of aromatic bismuth compounds belong eu- 
tloxin, orphol, dermol, bismuth sulpho-carbolate, cresolate and phe- 
nolate. 



DISEASES OF THE INTESTINE AND PERITONEUM 581 

ministered, stirred up in a little sugar-water or tea. It is astonish- 
ing how rapidly putrefaction in the intestine can be stopped by 
this treatment, as indicated incidentally, by the rapid disappear- 
ance of indican and other aromatic sulphates from the urine. 

The administration of other metallic salts, lead acetate, zinc Metallic salts 
sulphate, alum, or silver nitrate is not so common nowadays as it 
used to be. These remedies are all quite irritating to the bowel 
wall and the stomach, and as it is most important to prevent 
injury to the gastric wall in chronic catarrh of the intestine, the 
use of all these drugs must be considered somewhat precarious. 
The advantages derived from their antiseptic action are more 
than overbalanced by their irritating effect. The least harmful of 
all this group of medicines is silver nitrate, which is promptly Silver nitrate 
converted into silver chloride and silver proteid compounds in the 
stomach, both substances that possess only slight irritating pow- 
ers, but very powerful germicidal properties. Silver nitrate 
should be given in dessertspoonful doses of a 1 :100 solution, three 
or four times a day. 

In addition to the administration of antiseptics and astrin- Castor oil 
gents by mouth, free evacuation of the bowel should be promoted, 
especially in all cases of chronic intestinal catarrh accompanied 
by constipation; an occasional dose of castor oil in combination 
with an enema is, therefore, of benefit in these cases; or a variety 
of mineral waters may be employed. 

Just how mineral waters act in chronic intestinal catarrh is Mineral waters 
not understood. Empirically it is universally recognized that they 
favorably influence not only symptoms like constipation or diarrhea, 
but that they materially aid in restoring normal conditions about 
the bowel mucosa. That this good effect is not due alone to life 
at a resort where these waters are taken, or to rest and the proper 
regime that is carried out in these watering places, is shown by the 
benefits accruing to sufferers from chronic intestinal catarrh from 
the use of these waters at home. Alkaline and saline waters are the Alkaline-saline 
best, chief among them the waters of Carlsbad, Vichy, Marienbad. yJchv Mari- 
They should be taken hot, a tumblerful on rising, another one in enbad) waters 
the middle of the forenoon and a third in the middle of the after 
noon. The water should always be taken slowly in small swal- 
lows. Some patients cannot tolerate these waters on an empty 
stomach and they fare better if they take their first glass after 
breakfast. Waters of this type are most effective in cases of 
chronic intestinal catarrh associated with diarrhea. 

If there is much constipation, or if constipation and diarrhea Sulpho-saline 
alternate, then the sulpho-saline waters, or waters containing G-lau- waters 
ber salts, are best. These should be taken cold and the quantity 
administered should be gauged by the action of the bowels. The 



582 



DISEASES OF THE INTESTINE AND PERITONEUM 



Colonic flush- 
ings 



Opium in the 
diarrhea of 
chronic intes- 
tinal catarrh 



Hydrotherapy 



Rest and ex- 
ercise 



proper quantity is enough to produce free daily evacuations. These 
waters, too, are best given after a meal and not on an empty 
stomach. In order to be effective these mineral water "cures" 
should be kept up for long periods of time, i. e., their use should 
be continued at home and not only at the watering places for a 
few weeks once or twice a year. 

Colonic flushings and rectal irrigation are useful adjuvants 
to the treatment. In performing irrigation of the rectum and 
colon, either simple warm water or normal salt solution may be 
used. As a rule water of body temperature is the best. If, how- 
ever^ there is very much pain or irritation about the lower bowel, 
then hot irrigations of 105° to 110° F. are more grateful to the 
patient. Of antiseptics and astringents that may be employed 
to medicate the irrigating water, tannin, 5:1000; silver nitrate 
0.5:1000; salicylic acid, 1:1000; boric acid, 5:100; and creoline, 
1:1000, may be mentioned. Injections of 500 to 1000 cc. of olive 
oil, warm, are also very useful. 

Opium preparations should be given with care in the diarrhea 
of chronic intestinal catarrh, and only as a last resort in order to 
secure symptomatic relief from pain and to stop persistent diar- 
rhea that will not yield to any of the other measures spoken of 
above. The danger of opium treatment lies in this, that the drug 
by checking intestinal peristalsis favors stagnation of fermenting 
bowel contents, and hence may increase the bowel irritation. In 
view of the slightly irritating effect that opium occasionally exer- 
cises upon the gastric mucosa the drug is best given in the form 
of suppositories or hypodermic-ally, either alone or in combination 
with belladonna, or in combination with some of the above men- 
tioned astringent and antiseptic remedies. 

Hydrotherapeutic measures are of subordinate importance in 
the treatment of chronic intestinal catarrh. Priessnitz compresses 
applied to the abdomen are, however, useful and generally agree- 
able to the patient. If there is much diarrhea with violent peristal- 
sis and considerable irritation of the bowel and pain, a Winter- 
nitz compress, or hot turpentine stupes are very useful. In ob- 
stinate constipation, on the other hand, sitz baths, cold douches, 
Scottish douches, are often of great benefit. The latter measures 
with exact indications for their employment and the technique of 
applying them will be found described in full in the Sections on 
Diarrhea and Constipation. 

A patient suffering from chronic intestinal catarrh, especially 
with acute exacerbations, with persistent diarrhea, pain and tenes- 
mus, should remain in bed until the attacks of diarrhea are checked 
or greatly reduced. Cases of chronic intestinal catarrh with chronic 
constipation, on the other hand, should indulge in a mild amount 



DISEASES OE THE INTESTINE AND PERITONEUM 583 

of exercise. No fixed rules in regard to rest and exercise can 

be formulated, but the peculiarities of each individual case must 

be studied and rules made accordingly. 

The clothing and footwear should be carefully selected to pro- Clothing and 

footwear 
tect the patient from catching cold. In winter woolen underwear 

and stockings and thick shoes should always be worn. An ab- 
dominal binder made of flannel or wool should be worn all the 
year round. During the warm weather a hardening process may 
be begun and carried on into the winter, as described in the Sec- 
tion on Rhinitis. 



INTESTINAL STENOSIS AND OCCLUSION. 

Most cases of occlusion of the bowel, immaterial whether they Surgical vs. 
develop independently and suddenly or whether they develop jjl^t treat " 
less acutely on the basis of chronic stenosis of the bowel 
that gradually progresses to complete obliteration of the bowel 
lumen, are amenable to surgical treatment alone. Not infre- 
quently, however, a case will be encountered in which a restora- 
tion to normal conditions is produced by internal treatment. 
Such cases, in the very nature of things, are rare and constitute 
probably not one-third of all intestinal occlusions that are seen. 
This happy outcome manifestly can only occur under certain 
definite anatomic conditions to be specified below, whereas, in 
the majority of cases, the obturation of the bowel is of such a 
mechanical character that it can only be relieved by radical, 
mechanical, i. e., surgical, means. 

It will be seen, therefore, that the indications for internal or Indications for 
for surgical intervention are dependent altogether upon the na- medical treat- 
ture of the occlusion; and, as it is in most cases impossible to ment 
make an altogether positive diagnosis in this direction, internal 
treatment should only be employed tentatively and never for 
longer than forty-eight hours after the onset of the first symp- 
toms of bowel occlusion. If at the end of this time patency of 
the bowel lumen is not re-established, recourse should be had 
to surgery. The different internal measures, to be presently 
described, should, therefore, be tried quickly and in rapid suc- 
cession in the hope that one or the other of them may lead to the 
goal and obviate the necessity of a laparotomy. 

The following forms of bowel occlusion occasionally yield to 
internal treatment : 

Above all, fecal obstruction, i. e., occlusion of the bowel by Fecal _ ob- 
a plug of fecal matter occurring either as the result of obstinate structlon 
constipation and coprostasis, in an otherwise patent canal, or 



584 



DISEASES OF THE INTESTINE AND PERITONEUM 



Gall stone 
occlusion 



Occlusion from 
pressure from 
without 



Intussuscep- 
tion 



Volvulus, 
Kinks 



Strangulation 
Knotting 
Axial rotation 



occurring on the basis of a chronic narrowing of the lumen of 
the bowel by cicatricial stenosis or neoplastic growth from within, 
or by compression of the bowel from without by some en- 
larged or dislocated organ, by peritoneal adhesions or thicken- 
ing of the bowel wall. In the latter category of cases removal 
of the fecal obturator which may be very small or may consist 
merely of some coarse or indigested food particle^ is, however, 
more difficult than in simple fecal stasis. Occlusion of the bowel 
lumen by a large gall stone or some other foreign body is 
also amenable to internal treatment in a certain proportion of 
cases. Here, too, the presence or absence of chronic stenosis 
determines to a large extent the facility with which the obturator 
may be expected to pass on and out under appropriate medical 
treatment. The obstruction is (self -evidently) removed much 
more rapidly if the bowel lumen is normal throughout its course 
than if it is constricted or stenosed in some portion. Here the 
previous history of the case, the existence of stenosis symptoms 
prior to the occurrence of the occlusion, must, to a large degree, 
determine the treatment. 

Occlusion of the bowel by pressure from without, especially 
by compression of the bowel by large movable organs or tumors 
adjacent to the bowel, may yield to bandaging and manipula- 
tion and to placing the patient in certain positions in which the 
large abdominal mass that produces the compression is held away 
from the bowel. In this group such non-surgical treatment is, 
however, purely palliative and in most instances merely prelim- 
inary to an operation. 

Intussusception of the bowel also occasionally yields to in- 
ternal treatment (opium, atropine, lavage, irrigation — see be- 
low) ; most cases, however, do not. An attempt to relieve the ob- 
struction by non-surgical means should, therefore, always be 
made in these cases, but one should never persist in this treat- 
ment for longer than forty-eight hours at the utmost. Upon the 
appearance of collapse symptoms, or evidence of an impaired 
heart's action (see below) recourse should at once be had to surgi- 
cal means. 

The same rules, provided the diagnosis can be made at all, 
apply to volvulus and slight kinks of the bowel, although here 
the probability of restoring bowel patency by internal treatment 
is even smaller than in the case of intussusception. 

All the other forms of bowel occlusion, namely, firm strangu- 
lations, either internal or external, severe kinking or knotting 
of the bowel, double axial rotation, are surgical altogether from 
their onset and to waste time with internal measures in the treat- 
ment of these forms of ileus is bad practice, 



DISEASES OF THE INTESTINE AND PERITONEUM 585 

Even in the first named group of cases that may be said to Indications for 
occupy a position on the borderland between surgery and medi- Hminary medi- 
cine, a variety of elements about the general condition of the ca * treatment 
patient must determine the advisability of trying non-surgical 
means first, or of having recourse at once to operative interfer- 
ence. 

The considerations that should govern us in instituting 
preliminary internal treatment are the following: The method 
of treating any cases of internal occlusion by medical means, 
i. e., of adopting an expectant plan, is justified by the fact that 
about one-third of the cases recover without an operation. 
Of this group by far the greatest number, it is true, are due 
to fecal obstruction. Some clinicians claim, furthermore, that 
to wait is always good practice, because repeated examinations 
of the patient will enable the physician to make a better diagno- 
sis, to localize the seat of the obstruction and hence formulate 
more clean cut indications for surgical intervention. As a mat- 
ter of fact I have never found this to be the case; for if the 
tumor or swelling in the abdomen cannot be found on first ex- 
amination, it is usually still more difficult to find it later in 
the course of the disease, on account of the meteorism and the 
muscular rigidity that generally develop within twenty-four hours 
and renders the palpation of the abdomen much more difficult than 
in the beginning, even if an anesthetic is given. 

As against the expectant plan surgeons advance the just Arguments 
argument based on conservative statistics that the mortality from a f ^^nt Dlan^" 
an operation in this disorder increases in proportion to 
the length of time that is permitted to elapse between the onset 
of occlusion symptoms and the operation. They argue, further- 
more, with some justice, that internal treatment, especially the 
use of opium and the reduction of the intra-abdominal pressure 
by lavage or colonic irrigation, produces a sense of euthanasia, 
relieves the patient's distress and hence engenders a false sense 
of security in the patient, the friends and the physician; further- 
more, raises false hopes that are apt to be shattered; and, above 
all, favors loss of valuable time during which the intra- 
abdominal conditions are really being aggravated and the 
chances of recovery from surgical intervention are being re- 
duced. 

All these arguments, pro and con, would, it appears, speak Critique of 
directly for surgery in every case of bowel obstruction. Un- ^^1 ar £ u " 
fortunately, however, operative interference, even in the most 
skillful hands, is always dangerous in this disease, probably less 
gafe than laparotomy performed for almost any other acute 



586 



DISEASES OF THE INTESTINE AND PERITONEUM 



The heart's 
action 



Collapse 



intra-abdominal disorder. This is due to the peculiar condi- 
tions created by intestinal occlusion, the necessity in most cases 
of exploring large areas of the abdomen and of submitting many 
feet of the intestine to manual examination; the existence of 
meteorism with bowel distention, possibly paralysis of the bowel 
wall and, above all, in many cases, ulceration and great fria- 
bility of the intestine. In most cases, in fact, the operation will 
have to partake of the character of an exploratory laparotomy 
and often the surgeon will have to content himself with estab- 
lishing an artificial anus or performing a simple enterotomy, re- 
serving the radical operation for a second occasion, provided the 
patient should be so fortunate as to survive the shock of the 
first emergency inroad. Cases in which the exact location of 
the occlusion and its precise character are known before the oper- 
ation, or in which the occluded area is quickly found after 
laparotomy, are unfortunately relatively rare, and even in these 
the success of the operation is of necessity doubtful, as every- 
thing depends upon the mechanical conditions discovered and 
the possibility of relieving them promptly by surgery. 

Surgery is, therefore, by no means the panacea for occlusion 
of the bowel that one might imagine it to be. There are cases 
in which it is our only means of succor, but there are also many 
cases in which surgery, as well as medicine, is helpless, and there 
are still other cases, constituting, as stated above, about one- 
third, in which the patients get well without an operation. A 
conservative expectant plan with the adoption of all the non- 
surgical means we know of is, therefore, justified in the large 
class of cases delineated above, provided, of course, the patient 
is carefully watched during this time and everything is held in 
readiness for the operation should the necessity for it suddenly 
arise. 

So long as the heart's action is good, i. e., while the arterial 
tension is normal or slightly elevated, the pulse full, strong and 
of moderate rapidity; so long as no symptoms of acute strangu- 
lation or collapse (cold sweats, cyanosis, cold extremities, etc.) 
appear, it is generally safe to rapidly try all the non-surgical 
means. As soon as the heart begins to fail, the pulse becomes 
small, rapid and thready, the blood pressure low; if collapse 
occurs or signs of peritonitis or perforation develop, then no 
time should be lost in placing the patient on the operating table. 

The existence of collapse symptoms, appearing even one or 
two days after the onset of occlusion, or. collapse occurring from 
the initial shock of the occlusion, cannot be considered a contra- 
indication to surgical intervention; for without the operation 



DISEASES OF THE INTESTINE AND PERITONEUM 587 

these patients will surely die and with the aid of surgery they 
have at least a chance of recovery. Peritonitis or perforation do 
not prohibit a laparotomy; for in the light of modern surgical 
experience an occasional case of localized, even of mildly dif- 
fused peritonitis, unless too horribly septic, recovers after lapa- 
rotomy. 

The internist has a number of means at his disposal for over- The means of 
coming intestinal obstruction, chief among them lavage of the 
stomach, irrigation of the lower bowel, inflation of the rectum 
and colon with water or carbonic acid gas, the use of laxatives 
in some cases, of opium in others, massage, counter-irritation by 
means of heat or cold. The employment of mercury that was The use of 
formerly so popular in ileus is being discarded nowadays as ]^e CUry ° S °~ 
useless and occasionally harmful. 

For the application of all these measures distinct indications 
and contra-indications exist in the different forms of intestinal 
occlusion that may now be discussed. 4 

Lavage of the stomach and removal of the stomach contents, Lavage 
which is generally abundant and frequently contains fecal ma- 
terial, acts favorably in three ways, viz : 

First, lavage reduces the intra-abdominal pressure and hence 
greatly relieves the most distressing symptoms, especially vom- 
iting and flatulency; at the same time it decreases the violence 
of peristaltic movements and favors the straightening of kinked 
or twisted bowel loops. 

Second, lavage causes removal of a mass of toxic material 
accumulating in the stomach that may do serious harm by pro- 
ducing general symptoms of toxemia, especially about the heart 
and nervous system, if allowed to remain behind or if only in- 
completely evacuated by spontaneous vomiting. 

Third, lavage in many cases, materially aids in the evacuation 
of the bowel contents above the constricted area; for as soon 
as the stomach is thoroughly emptied by lavage, regurgitation of 
bowel contents into the stomach occurs, so that within a few 
hours the stomach will generally be found full again. In some 
cases during the performance of lavage new masses of fecal mat- 
ter will suddenly appear in the stomach even after the wash 
waters were already clear, showing how rapidly bowel contents 
in this condition can regurgitate into the stomach. 

It is obvious, therefore, that in cases of bowel occlusion Time of per- 
lavage of the stomach should be performed repeatedly and at s vag 

short intervals. It is always good treatment to wash out the 
stomach at two or three hour intervals until nothing more of 
fecal material can be pumped out. It is unnecessary to wait for 
fecal vomiting before performing lavage, as removal of the 



588 



DISEASES OF THE INTESTINE AND PERITONEUM 



Contra-indica- 
tion 



Bowel irriga- 
tion 



Contraindica- 
tions 



stomach contents, even if it is not contaminated with bowel con- 
tents, is good practice on account of the reduction of the intra- 
abdominal pressure and the removal of toxic stagnating mate- 
rial that is thereby brought about. Moreover, the stomach may 
contain abundant fecal material and still no fecal vomiting occur. 

The one contra-indication to gastric lavage is severe collapse. 

In cases that are distinctly surgical in character and in which 
an operation has been decided upon, gastric lavage is also of 
signal benefit; for it is manifestly easier to manipulate the bowel 
after laparotomy if the stomach is small and empty than if it is 
large, heavy and distended, and occupies a large space in the 
abdomen; besides the danger of vomiting under an anesthetic 
and the occurrence of pneumonia from aspiration of foul vom- 
ited material is greatly reduced if lavage of the stomach is per- 
formed as a preliminary to the operation. 

Bowel irrigation is always of value in intestinal occlusion. 
In ileus, due to fecal obturation, it is, of course, the sovereign 
remedy. It is generally of use in impaction of a gall stone or of 
some other foreign body. In occlusion of the colon it is self- 
evidently of value, immaterial whether the occlusion is due to 
the impaction of a fecal plug in a chronically stenosed, con- 
stricted area of the colon, or whether the ileus is due to invagin- 
ation with the abdominal mesentery. In most cases irriga- 
tion of the lower bowel acts mechanically by softening and re- 
moving the fecal plug or loosening the impacted foreign body. 
In invagination the use of an eight to ten per cent, salt solution 
(see below) by producing anti-peristaltic waves may even act 
directly curatively; for as soon as the anti-peristaltic waves 
reach the invaginated area the obstruction may disappear. In 
kinks or twists of the sigmoid flexure irrigation helps both by 
removing heavy, dragging fecal masses and producing stretch- 
ing and straightening of the affected bowel section; and, even in 
ileus in the small intestine, the peristaltic and anti-peristaltic 
waves that are stimulated may be of signal benefit in promoting 
restoration of bowel patency. 

There are distinct contra-indications to the use of rectal or 
colonic irrigation, namely, ulceration or great friability of the 
bowel wall that may be suspected and feared in a variety of dis- 
orders that produce intestinal occlusion. It is also clear that 
rectal irrigation should not be repeated if, in a given case, the 
first enema does not promptly return, or if the patient is alto- 
gether unable to retain the injected fluid. In some cases irriga- 
tion of the bowel becomes impossible on account of the presence 
of large, hard masses of impacted feces in the rectum or lower 
bowel. Here an attempt should always be made to soften the 



DISEASES OF THE INTESTINE AND PERITONEUM 589 

latter by the injection of small quantities of oil or, if necessary, 
to remove them mechanically with a blunt spoon or some 
other instrument. 

The technique of rectal irrigations and of colonic flushings Solutions to be 
has already been described. The best irrigation fluid in emp oye 
ileus is a ten per cent, solution of sodium chloride in water. 
Salt solutions of this concentration produce anti-peristaltic 
waves so that the water is often carried up as far as the lower 
portion of the ileum. One other great advantage of these 
strong salt enemata is that only small quantities, i. e., from 300 Strong salt 
to 400 cc. need be injected in order to produce the same effect, enemata 
or even a greater one, than would ordinarily be produced by 
the introduction of several litres of any other injection fluid. 
By using these strong salt enemata, therefore, the increase of 
the intra-abdominal tension and excessive stretching or disten- 
tion of the bowel is avoided. The addition of a few ounces of 
infusion of senna, or of some other laxative infusion to the salt 
clysma, can do no harm, but is, as a rule, superfluous. 

The use of cold enemata or of ice water given for the pur- Cdld enemata 
pose of stimulating peristalsis is always dangerous, especially in 
cases threatened with collapse or actually in collapse. This meas- 
ure is unnecessarily severe and in view of the diagnostic 
uncertainties obtaining in each case of bowel occlusion, and the 
inability to predict in advance whether or not stimulation of 
peristalsis is desirable (see below), it is sometimes decidedly pre- 
carious. Small clysmata of warm water or of physiological salt 
solution are much better. They should be injected very slowly 
in order to avoid over-distention of the bowels. Rectal irrigation 
should be performed at intervals of three or four hours until the 
bowel passage is cleared or the time for operation has arrived. 

Injections of one-half to one litre of lukewarm olive oil can al- Oil injections 
ways be given with safety as a preliminary measure. They are 
very useful to soften and dissolve hardened fecal masses or to loosen 
a fecal plug to render the way open for the passage of after-coming 
bowel movements. 

Inflation of the lower bowel with air or carbonic acid gas Air inflation 
possesses no particular advantages, so far as its mechanical effect 
is concerned, over the injections of water, oil or salt solutions; 
as the latter, aside from distending the bowel, aid in cleaning out 
the intestine, they are by all means preferable. Following a series 
of fluid injections an air or carbonic acid gas inflation may, 
however, be practised to advantage, especially as this method of 
distending and stretching the lower bowel is often better borne 
and less distressing to the patient than distention with the heavier 
fluid irrigations. Inflation, too, is particularly useful in invagina- 



590 



DISEASES OF THE INTESTINE AND PERITONEUM 



Technique of 
inflation 



Opium 



Objections to 
opium 



Rationale of 
opium 



tion and in kinks or partial rotation of the sigmoid flexure. The 
same contra-indications to the nse of air and gas inflation exist as 
in the case of water injections, namely, friability of the bowel wall 
and ulceration, provided the existence of these conditions can be 
determined, or is even strongly suspected. 

To perform inflation of the rectum and colon with air a rectal 
tube is joined by a T tube with an air bulb. The free limb of 
the T tube is connected with a piece of rubber tubing held shut 
with a clamp. When it is desired to allow the escape of 
air from the rectum, this clamp is opened. To inflate the rectum 
with carbonic acid gas the rectal tube may be connected with an 
ordinary siphon and carbonated water injected into the bowel, 
or a watery solution of bicarbonate of soda is injected first and 
a solution of tartaric acid immediately afterwards. Of the former, 
twenty grammes, of the latter, fifteen grammes are commonly 
used. 

A violent controversy has been going on for many years be- 
tween physicians and surgeons in regard to the administration 
of opium in occlusion of the bowel. Internists generally ad- 
vise its use in all cases as a routine measure in the beginning of 
the disease. Surgeons, on the other hand, condemn its employ- 
ment, claiming, as stated above, that it produces merely a 
sense of euphoria, lulls the medical attendant into a sense of 
false security, permits aggravation of the bowel condition and 
favors waste of valuable time before the operation is finally per- 
formed. 

Inasmuch, however, as opium certainly relieves the suffering 
of the patients and in some cases, by reducing peristaltic move- 
ments, directly aids in restoring normal conditions, its use during 
the first twenty-four hours is indicated and can be advised. If, 
at the end of this time, the bowel lumen is not open, the sur- 
geon in any doubtful case comes into his right anyhow, and so 
much at least has been gained by the administration of opium 
that the patients remained relatively comfortable during the 
time that internal treatment was administered. That severe 
collapse symptoms from reflex irritation emanating from the 
bowel and peritoneum are often prevented and that the section 
of bowel immediately above the obstruction is not so unduly 
stretched and injured by continuous packing of bowel contents 
into this area, when opium has been given to allay the violent 
peristaltic movements of the bowel, must be conceded. Even in 
those cases, finally, that are surgical from their onset, opium 
can do no harm. On the contrary it usually does good by pre- 
venting collapse, by quieting the general sensibilities and nervous- 
ness of the patient and also by reducing the violence of peristalsis. 



DISEASES OF THE INTESTINE AND PERITONEUM 591 

The surgeon's plea against opium, provided the drug is given only 
during the first twenty-four or forty-eight hours, cannot, there- 
fore, be considered valid. 

To summarize, opium is permissible in all cases of intestinal Summary 
occlusion. In cases that are clearly surgical from their onset 
(and to know this is one of the most difficult and uncertain tasks 
of diagnosis) the drug can do no harm when given as a prelim- 
inary to the operation. In cases in which the diagnosis is alto- 
gether doubtful opium should be given for twenty-four to forty- 
eight hours, first, for the purpose of relieving the patient's anxiety 
and restlessness, and to allay the vomiting and mitigate the ter- 
rific pain; second, for counteracting the sudden, early collapse 
from reflex irritation emanating from the sensory nerves of the 
intestinal peritoneum; third, for reducing the over- violent intes- 
tinal peristalsis and hence preventing to some extent, damaging 
paralysis, ulceration or perforation in the bowel area situated 
immediately above the obstruction. In certain forms of intestinal 
occlusion, finally, chiefly invagination, volvulus or slight degrees 
of kinking or twisting of the bowel, the arrest of peristalsis that is 
brought about by opium, combined with other measures (lavage, 
irrigation, etc.), may even aid in restoring normal condi- 
tions. 

In order to be effective large doses of the drug should be Dose and ad- 
given early in the disease. As the absorptive powers of the mmistratl0n 
stomach are usually greatly reduced or inhibited in occlusion of 
the bowel and as opium, moreover, is a distinct irritant to the 
gastric mucosa and may precipitate vomiting, it is best adminis- 
tered not by mouth but in suppository or hypodermically. The 
exact dosage depends somewhat on the reaction of the individual 
to the opiate. The proper dose in any case is enough to produce 
the desired effect. It is best given in amounts of half a grain 
(0.03 gm.) of the extract, every one or two hours, in suppository or 
in the form of a watery solution of the extract of the strength of 
1 :10. Of the latter, an amount corresponding to about a third of 
a grain (0.02 gm.) should be injected every two hours until the 
desired effect is produced; or morphine should be injected in the 
dose of an eighth to a fourth of a grain, every two or three 
hours, until the patient is clearly under the influence of 
the drug. 

If the rule is observed not to rely upon opium for longer 
than forty-eight hours in cases in which the bowel lumen is not 
reopened by that time, no harm can be done and the most serious 
objection against its use, namely, production of a false sense of 
security, is rendered invalid. After forty-eight hours have 
elapsed the administration of opium is unnecessary unless the 



592 



DISEASES OF THE INTESTINE AND PERITONEUM 



Opium in 
collapse 



Atropine 



drug is given for purposes of euthanasia in cases in which an opera- 
tion cannot be performed. Above all things, it is important to 
remember that the relative comfort of the patient when under the 
influence of opium should never constitute a contra-indication to 
an operation. The only criterion that should guide the internist 
in advising an operation is whether or not the bowel is open at the 
expiration of forty-eight hours; for, while some cases have been 
known to live for many days with complete occlusion of the bowel, 
this event is exceptional. 

Whereas opium may be considered an efficient remedy to 
prevent the occurrence of collapse early in occlusion of the bowel, 
it should be given with great care in collapse occurring later, 
i. e., after the expiration of twenty-four or forty-eight hours, 
an accident that is especially liable to happen in cases that have 
not had the benefit of opium treatment from the beginning. To 
give large doses of opium suddenly in these instances is a precarious 
matter; for the weak heart, the peripheral cyanosis, the cold ex- 
tremities, the rapid, thready pulse constitute direct contra-indica- 
tions to the use of the drug. If, in such patients, it becomes neces- 
sary on account of the great pain to give opium or morphine, then 
these drugs should, by all means, be administered in combination 
with some analeptic like ether, camphor or ammonia to support 
the heart. 

Atropine should be given with the same reservation as opium. 
No time should be wasted with atropine treatment in clearly op- 
erative cases, nor should its use ever be continued for more than 
two days. Any patient with occlusion of the bowel who is treated 
with atropine should be carefully watched and if resolution does 
not promptly occur, recourse should be had to an operation. It is 
known empirically that atropine is occasionally highly effective in 
causing reopening of the bowel lumen. All the favorable cases, 
however, were presumably due to fecal obstruction or occlusion of 
the bowel by a large gall stone or other foreign body, or cases 
of "dynamic" ileus. In view of the difficulty of diagnosing the 
precise character of the occlusion, it is clear that too much re- 
liance should never be placed upon atropine, especially as its 
mode of action in these cases is very obscure. It is doubtful how 
the remedy acts, whether it reduces secretion in the bowel above 
the obstruction and hence prevents distention of this intestinal 
area with fluid, or whether it aids by contracting the blood vessels 
in the occluded area and hence reduces the thickness of the bowel 
wall. Atropine should be given, hypodermically, in large 
doses of a sixtieth to a thirtieth of a grain (0.001 to 0.002 gm.), 
three or four times in the course of thirty-six to forty-eight hours. 
If the bowel passage is not opened after the third injection, 



DISEASES OP THE INTESTINE AND PERITONEUM 593 

then it is useless to continue the exhibition of atropine any fur- 
ther. 

It will be seen, therefore, that the use of atropine in ileus in- 
variably partakes of the character of a therapeutic experiment 
that, in rare cases, produces brilliant results, but unfortunately, 
in the majority, produces no results whatever. As no harm can 
ever accrue to the patient from the use of atropine, especially if 
lavage, irrigation, etc., are performed at the same time, and pro- 
vided valuable time is not wasted thereby in clearly surgical cases, 
the administration of three or four doses of the drug can be rec- 
ommended in most cases. This applies even to cases of ileus that 
develop on the basis of a chronically stenosed bowel; for here the 
removal of the fecal plug, or the foreign body, which may have 
produced the complete occlusion has occasionally been facilitated by 
atropine. In cases, finally, that are clearly due to fecal obstruc- 
tion or to impaction of a gall stone in an otherwise normal in- 
testine it is especially useful. 

Laxatives are distinctly contra-indicated in all forms of acute Laxatives 
intestinal obstruction, with the possible exception of fecal occlu- 
sion of the bowel. If the latter diagnosis can be positively made, 
and this will be an exceptionally rare event, laxatives may be 
safely given. Even in this group of cases, however, they should 
be given early in the disease as otherwise paralysis of the bowel 
wall above the fecal plug may have supervened. In this case 
removal of the fecal plug by the use of laxatives would not mate- 
rially relieve the situation; for the mass of after-coming Itowel 
contents would be packed forcibly into the paralyzed area which, 
being unable to propel this mass onward, would in its turn be- 
come obstructed by a new and more bulky fecal plug. Besides, in 
fecal obstruction of somewhat longer standing, especially when 
it develops upon the basis of a chronic progressive stenosis of 
the bowel, there is always danger of ulceration and increased 
friability of the intestinal wall above the obstructed area, so that 
in these cases the administration of laxatives favors rupture or 
perforation. Several cases are on record in which this 
accident occurred after the administration of laxatives. 

In cases of ileus, finally, in which the character of the occlu- 
sion is doubtful laxatives should, by all means, be withheld; for 
if the bowel occlusion is not due to fecal obstruction they may do 
serious harm even if given early. 

In nearly all cases of ileus laxatives increase distress of the 
patient, especially the vomiting and the pain. Oftentimes, in 
fact, fecal vomiting only occurs after the administration of pur- 
gative drugs. On account of the increased pain and peristalsis 
that may be produced by these remedies, collapse, too, may be 



594 



DISEASES OF THE INTESTINE AND PERITONEUM 



precipitated by their use. Finally, purgatives may do decided 
harm in ileus due to knuckling of the bowel, strangulation, axial 
rotation or intussusception. This can sometimes be positively de- 
termined, in cases that present favorable conditions for examina- 
tion, by palpation of the abdomen; for upon the administration 
of laxatives the abdominal tumor will be felt to grow harder and 
larger. In occlusion due to a foreign body or to a gall stone 
impaction, purgatives do very little good; for the bowel 
wall is already putting forward its maximum effort to pro- 
pel the obstacle onward, and to over-stimulate peristaltic move- 
ments that are already abnormally exaggerated can only do 
harm. 

It will be seen, therefore, that laxatives are preferably alto- 
gether avoided in any form of ileus unless the case is one of very 
recent fecal obstruction occurring in an individual whose bowel 
movements, up to the time the ileus occurred, were normal in 
calibre. Late in fecal obstruction, or in any other form of sud- 
den occlusion of the bowel, laxatives are best avoided. In view 
of the great difficulty of making a positive diagnosis of fecal ob- 
struction in any case the administration of laxatives in genera] 
is to be condemned. 

Massage Massage of the bowel performed by an expert masseur, pref- 

erably under an anesthetic, sometimes aids, when used in com- 
bination with other measures, in relieving occlusion of the bowel 
due to a fecal plug or an impacted gall stone or foreign body. 
Massage may be performed either by directly kneading and push- 
ing the obturation onward, or by stimulating the bowel wall, 
around and immediately above the occluded area, to increased 
contractions. Here, again, this method of treatment is dangerous 
in cases of fecal occlusion or foreign body obturation that are 
not quite recent, on account of possibly causing rupture of the 
friable intestine or of producing perforation of a stercoral ulcer 
that may have formed in the area of coprostasis. 

In all the other forms of intestinal occlusion massage must be 
considered altogether dangerous, especially on account of the 
friability of the intestinal wall,, and the danger of ulceration 
or gangrene about the occluded area. In fecal obstruction of the 
colon, however, massage of the large intestine, preceded by an 
oil injection to soften the fecal plug, is of considerable value, 
but, even in this variety of cases, one can get along very well 
without massage. Consequently this method of treatment, which 
was formerly very popular, must be considered to have an ex- 
ceedingly limited field of application. 

Electricity Electric treatment is, in most cases, a waste of time. The 

only condition in which it might do some good would be in 



DISEASES OF THE INTESTINE AND PERITONEUM 595 

bowel paralysis following the removal of the obturator. This 
sequel of ileus may be treated by applying two electrodes to 
the abdominal surfaces and passing a strong faradic current 
through them, or by applying one pole to the abdomen and in- 
serting the other one in the rectum and using a galvanic current. 
Either form of current should be used in the same man- 
ner and same strength as described in Stomach Diseases. 

Hot or cold applications to the abdomen in the form of hot Hot and cold 
water bags, stupes, compresses, a thermophore or a Leiter coil a PPhcations 
charged with hot or cold water are useful as counter-irritants, 
chiefly to aid in controlling the pain. If peritonitic symptoms 
appear, cold is more useful than heat, otherwise the sensations 
of the sufferer alone must be considered and heat or cold applied 
according to the likes and dislikes and the general reaction of the » 

patient. 

In cases of very extreme meteorism in which surgical relief Meteorism 
cannot be promptly obtained, or in which the patient or rela- 
tives refuse an operation, puncture of the intestine with a fine Puncture of 
needle trocar not larger in caliber than the needle of a hypo- the D °wel 
dermic syringe, may be performed in order to promote the escape 
of gases. In this way the intra-abdominal pressure may be ma- 
terially reduced and some symptomatic relief obtained. In addi- 
tion, the reduction of the pressure occasionally aids in relieving 
certain forms of intestinal obstruction. Here the same effect is 
produced as by the relief of abdominal pressure by stomach lavage. 
Paracentesis of the bowel must, however, always be considered 
a very precarious procedure and one that should never be resorted 
to in any case in which a laparotomy can be performed, or in 
which there is any possible way to obtain relief of the meteor- 
ism by other means. The chief danger from puncture of the bowel 
is evidently the development of peritonitis, especially in cases in 
which the bowel is paralyzed or gangrenous. Under these con- 
ditions the puncture opening may not close promptly or com- 
pletely and bowel contents ooze into the peritoneal cavity. Inas- 
much as over-distention of the bowel from excessive meteorism 
frequently leads to paralysis or even gangrene, it will be seen 
how dangerous this operation is. In fact, the interference with 
the normal blood supply in the bowel, that commonly results from 
the over-stretching of the bowel wall, renders it possible for gan- 
grene to develop secondarily about the trocar opening, so that 
perforation or rupture of the bowel and peritonitis may follow 
some time after the puncture has been performed. The operation, 
moreover, is not always easy to perform and it may occasionally be 
necessary to insert the needle several times before a loop of bowel is 
actually punctured; or the bowel may be punctured but no gas 



596 



DISEASES OF THE INTESTINE AND PERITONEUM 



Diet 



Thirst 



Hypodermo- 
clysis 



Rectal feeding 



Diet in chronic 
stenosis 



escape, so that a second or a third insertion of the needle may be- 
come necessary. Under these conditions, the dangers resulting 
from the puncture are, of course, still more increased. 

Very little need be said in regard to the diet in cases of 
acute intestinal occlusion. Complete abstinence from solid or 
liquid food is absolutely necessary. The introduction of any food 
by mouth can only increase the accumulation of material behind 
the obstacle. In ileus, the administration of food or drink is a 
useless procedure inasmuch as the power of the stomach or intes- 
tine to absorb any of the gastric or intestinal contents is prac- 
tically inhibited. Moreover, vomiting, which may be aggravated 
by the introduction of food, would promptly expel everything 
that might be introduced into the stomach. There is rarely any 
difficulty in maintaining total abstinence from food, as the pa- 
tients themselves never manifest a desire to eat anything. 

Most of them, however, suffer from excessive thirst. This 
symptom is usually materially allayed by the use of opium, as 
described above. If the thirst is very distressing, it may be 
somewhat relieved by allowing the patient to suck a little ice, 
or to allow ice pills moistened with a few drops of brandy to 
dissolve in the mouth. They should always be instructed not to 
swallow the water. Washing out the mouth at frequent intervals 
with plain water or soda solution is usually very grateful to the 
sufferers. 

The administration of water by hypodermoclysis in the form 
of normal salt solution, or in the same form by rectal irrigation, 
is a useful means of supplying to some extent the water demands 
of the organism. 

Rectal feeding, however, is rarely indicated, especially if an 
operation is performed within forty-eight hours after the onset 
of the trouble in all cases that do not yield to other means by that 
time. 

In chronic stenosis of the bowel in which the time for opera- 
tion has not yet arrived, or in which the conditions producing 
the stenosis are unalterable, or in which the patient refuses an 
operation, the diet should, as a prophylactic means, be arranged 
in such a way as to prevent a sudden occlusion of the stenosed 
area. In order to fulfill this purpose a diet that leaves the 
smallest possible residue in the bowel and that contains no coarse 
particles that might form a plug in the stenotic area, is advis- 
able. The food, therefore, should consist largely of milk, eggs, 
broths, strained gruels, vegetable purees, butter, cream, scraped 
or hashed meats, carefully freed from skin and tendons. Raw 
fruit and vegetables containing seeds, stems, pips, kernels, skins, 
etc., cereals containing husks, pips, seeds, stems, skins, coarse 



DISEASES OF THE INTESTINE AND PERITONEUM 597 

breads and similar foods should be absolutely forbidden. The 
patient should be instructed to most carefully masticate his food 
and to eat small meals at a time. 

Any tendency to constipation should be overcome by giving Constipation 
fruit sauces and abundant fat with the diet and by instructing 
the patient to drink olive oil once or twice a day. At the same 
time the lower bowel should be kept thoroughly cleaned out by 
means of enemata, and, with great care, mild vegetable laxatives 
like cascara, rhubarb, senna, etc., or gently-acting laxative wa- 
ters, or an occasional dose of castor oil may be administered. 
In cases, however, in which the stenosis has advanced to such 
a point that the peristaltic action of the intestine is greatly in- 
creased, as manifested by the appearance of visible and pal- 
pable peristaltic waves on the abdomen, laxatives of any 
kind are, to say the least, superfluous. For, in these cases, the 
bowel wall is manifestly already putting forward its maximum 
effort to overcome the obstruction. Here, in fact, much more can 
be gained from the administration of opium, for reasons that 
have been discussed in full above, than from the administration of 
laxatives. 

In sudden intestinal occlusion occurring on the basis of a 
chronic stenosis of the bowel, the same rules of treatment obtain 
as in any other form of acute ileus, only that here the indications 
for surgical intervention are more exact and positive, because 
generally abundant time has been given to determine the nature of 
the lesion and its precise location in the abdomen. 



INTESTINAL ULCER. 

The treatment of ulcer of the bowel is largely limited to the 
symptomatic relief of the diarrhea, the pain and the hemor- 
rhages. 

The causal treatment of ulceration of the bowel occurring in Causal treat- 
the course of different infectious diseases, as tuberculosis, ty- 
phoid, dysentery, erysipelas, variola, sepsis, etc., is synonymous 
with the treatment of the underlying disorder. The same ap- 
plies to the causal treatment of intestinal ulcers occurring in the 
course of leukemia, gout, the hemorrhagic diathesis, or in uremia. 
Syphilitic ulcers of the bowel are self -evidently amenable to anti- 
luetic treatment. Stercoral ulcers occurring as the result of 
chronic constipation or in stenosis of the bowel, if they are at all 
discovered before perforation occurs, should be treated by correc- 
tion of the underlying constipation, or mechanically, i. e., by sur- 
gical correction of the stenosis of the bowel lumen. The radical 



598 



DISEASES OF THE INTESTINE AND PERITONEUM 



Rest in bed 



Diet 



Hot and cold 
applications 



Internal reme- 
dies 



Bismuth 



Opium 



removal of an ulcerous area by excision may be included under 
the possible methods of causal treatment. 

A patient, with an intestinal ulcer producing much diarrhea, 
or causing much pain and showing a tendency to hemorrhage, 
should remain in bed. The diet, broadly speaking, should be ar- 
ranged according to the same principles that obtain in chronic 
catarrh with diarrhea, i. e., it should be free from mechanical, 
chemical or thermical irritants, should be easily digestible and, 
at the same time, sufficiently nutritious to maintain the physical 
equilibrium of the patient. The ideal, therefore, is a nutritious 
liquid or semi-liquid diet consisting largely of milk, broths, milk 
dishes, strained gruels, etc., given in small quantities and at fre- 
quent intervals. 

Heat or cold applied to the abdomen in most cases materially 
aid in relieving the severe distress of the patient and in reducing 
violent peristaltic movements of the bowel; they, therefore, act 
curatively, in a sense, by allowing the bowel to remain at rest and 
by checking the diarrhea. If there is evidence of peritonitic irri- 
tation, cold applications to the painful area, provided it can be 
definitely localized, are the best, otherwise, heat, either dry or moist, 
is more pleasant to the patient and probably more efficacious. The 
patient should be instructed to keep the ice bag or the hot water 
bag, or the Leiter coil, or the compress continuously in 
place. 

Very little can be expected from internal remedies given for 
the purpose of healing an intestinal ulcer. The most popular 
preparations and the ones that are almost universally employed 
for this purpose are bismuth salts and tannin derivatives. If bis- 
muth is given, it should be administered in large quantities prefer- 
ably in pills coated with salol; for the latter resist the acid gastric 
juice and are not dissolved until they reach the alkaline medium 
of the intestine. It is questionable whether even large doses of 
bismuth can really form a coating over one or multiple ulcers 
when distributed throughout the length of the small intestine. 
Bismuth may be given in the form of the subnitrate or the sub- 
gallate, or as dermatol in doses of fifteen to twenty grains (1 to 1.3 
gm.), several times a day. 

Together with the bismuth a quarter or an eighth grain of 
opium can, to advantage, be administered; for both the bismuth 
and the opium possess hemostatic and anti-diarrheic properties 
and the latter, moreover, acts as an anodyne in painful ulcers. If 
opium is to be administered alone, it is better given in suppository 
or clysma, or hypodermically, than by mouth, especially if larger 
quantities are to be administered. 



DISEASES OF THE INTESTINE AND PERITONEUM 599 

The best tannin preparations are tannalbin or tannigen, given Tannalbin 
either alone or with opium. The antiseptic properties of the Tannigen 
tannin preparations combined with the anti-diarrheic and anodyne 
properties of opium make this a useful combination. 

Ulcers of the colon and rectum are amenable to local treat- Ulcers of 
ment. Here astringent and disinfectant irrigations may be em- rectum 
ployed. The safest disinfectant solutions are thymol, 1:100; sali- 
cylic acid or boric acid, 1 :500. Bichloride of mercury injections Astringents 
or solutions of carbolic acid should never be employed in ulcera- ants 
tion of the lower bowel, as there is always danger from this prac- 
tice of producing general carbolic acid or mercurial poisoning. 

The most useful astringent solutions are silver nitrate, 1 :100 ; 
or tannic acid in the same strength. Silver nitrate injections 
or instillations frequently produce violent tenesmus. If these 
painful sensations persist for some time, or become unbearable to 
the sufferer, then an injection of a salt solution will cause pre- 
cipitation of the silver nitrate as silver chloride and stop the irri- 
tation. 

In case of intestinal hemorrhage, complete rest in bed and Intestinal 
total abstinence from food should be insisted upon. Even" aftei emorr a S e 
the hemorrhage has stopped the diet should be liquid, exclusively, 
for several days or longer, i. e., until even chemical traces oi 
blood have disappeared from the stools. The application of the 
ice bag to the abdomen is useless unless there is evidence of peri- Opium 
tonitic irritation. The best remedy is opium given in suppository 
or by mouth ; it acts chiefly by arresting peristalsis, and hence plac- 
ing the bowel at rest and favoring clotting and arrest of the hemor- Ergot 
rhage. Ergot, given as the fluid extract in the dose of one to 
two drachms (4 to 8 cc), or as the dry extract in the dose of three 
to fifteen grains (0.2 to 1 gm.), by mouth, or as the injectio ergo- 
tina hypodermica, three to ten drops, is, in my experience, of very Hydrastis 
doubtful value. Much better is hydrastis given as the fluid ex- 
tract in doses of fifteen to sixty minims (1 to 4 cc), or 
as hydrastinine hydrochlorate, in doses of one-half to two 
grains (0.03 to 0.1 gm.), or as stypticine, in the dose of 
one-third to one-half grain (0.2 to 0.3) several times a day. 
Hamamelis, in the form of the fluid extract, in thirty minim Hamamelis 
(2 cc.) doses, repeated several times, is also a useful remedy. 
Very good results are often obtained from the use of adrenalin Adrenalin 
chloride, given in ten to fifteen drop doses of a 1:1,000 solution, 
several times at two or three hour intervals. Calcium chloride, Calcium 
in thirty grain doses (2 gm.) in watery solution, repeated sev- 
eral times, is also a method of treatment that is worthy of a trial. 
The latter remedy, of course^ is given with the object merely of 
promoting coagulation. 



600 



DISEASES OF THE INTESTINE AND PERITONEUM 



Gelatin 

Bismuth 
Lead acetate 
Perchloride of 
iron 



Hemorrhages 
from colon or 
rectum 



Collapse and 
secondary hem- 
orrhage 



Gelatin solutions are also occasionally of use; they should be 
administered as described in the Section on Hemoptysis. Bis- 
muth and lead acetate and, above all, the perchloride of iron, three 
preparations that are very popular, are, in my experience, utterly 
devoid of value in arresting intestinal hemorrhages. It is possible 
that the perchloride may be effective indirectly in large hemor- 
rhages by causing the formation of a clot that acts as a tampon 
in the intestine. 

In hemorrhages occurring from ulcers of the colon or the rec- 
tum, irrigations with hot water are usually effective. Ice water 
injections are, as a rule, dangerous because they produce active 
peristalsis, which prevents clotting of blood and may lead to 
further hemorrhage. In very extreme cases, however, that resist 
all other treatment, ice water applied directly to the bleeding spot, 
provided it can be seen through the rectoscope or sigmoidoscope, 
may be tried as an emergency measure. The addition of tannin, 
silver nitrate or alum to the hot water can do no harm ; better still 
are calcium chloride solutions, employed in the strength of 4:1,000, 
for the latter salt in many cases aids in the local coagulation of 
the blood. Adrenalin solutions; solutions of the fluid extract of 
hamamelis; or a solution of gelatin 10:200, all administered in 
small quantities by rectum, are also often efficacious in arresting 
hemorrhage of the large intestine. 

The treatment of collapse symptoms occurring upon the on- 
set or during the course of an intestinal hemorrhage, and the 
treatment of the secondary anemia that generally follows severe 
intestinal bleeding, has already been discussed in full in different 
sections of this book (see index). 



MEMBRANOUS ENTERITIS AND MUCOUS COLIC. 



Definition The excretion of large quantities of mucus may accompany 

any form of intestinal catarrh; it may also occur without enter- 
itis. Inasmuch as most cases of intestinal catarrh run their 
course without the expulsion of abundant mucus, one must postu- 
late, in that variety in which mucous stools occur, the existence 
of some specific element that determines the excretion of mucus. 
The exact character of this element is uncertain, but, in all prob- 
, ability it is a general neuropathic disposition with or without 
enteroptosis that upon the incidence of certain determining fac- 
tors like intestinal catarrh in enteritis membranacea, or chronic 
constipation in simple mucous colitis (colica mucosa), leads to 
over activity of the secretory glands of the bowel. 

In enteroptosis the best results are obtained by manipulative 
treatment directed towards strengthening the muscles of the back 



DISEASES OF THE INTESTINE AND PERITONEUM 601 

and the abdomen and by postural treatments intended to replace the 
dislocated organs. In the hands of a skillful manipulator, with the 
patient in the Trendelenburg position, this mechanical treatment 
is most useful in bringing the organs back into their normal place. 
Each time after reposition has been accomplished, the patient should 
remain for at least an hour in the Trendelenburg position. A use- 
ful adjuvant to this treatment is the imposition of a sack of sand 
over the lower abdomen that exercises enough pressure to gently 
brace the lowered organs against the diaphragm. In some cases 
the placing of such a sand bag over the patient's lower abdomen, 
with the hips elevated, may be carried on for weeks, while the pa- 
tient at the same time undergoes a fattening cure in bed. 

As a matter of fact, a nervous disposition and general neu- Neurotic ele- 
rotic manifestations will be found in nearly all cases suffering 
from either of the two diseases under discussion. Causal treat- Causal treat- 
ment in any case must, therefore, attack the underlying neuras- 
thenia or hysteria. In cases suffering from true enteritis, the 
intestinal catarrh must be treated, whereas in cases of mucous 
colitis, it is, of course, useless to treat a hypothetical catarrhal con- 
dition that does not really exist. 

As a prophylactic measure and as an important symptomatic 

treatment during the attacks, the evacuation of the mucus must 

be accelerated by artificial means; for in this way the attacks of 

colic are mitigated and abbreviated, or altogether aborted. m 

6 . . Treatment of 

The treatment of the underlying neurasthenia or hysteria the neurosis 

must be carried out according to the principles that have been 
described at length in the Section on Gastric Neuroses. A rest 
cure with isolation, or a Weir Mitchell treatment; various 
hydrotherapeutic or electro therapeutic measures; the removal of 
reflex irritation emanating from any organ of the body; change 
of scene; a pause in the daily routine; respite from worry 
and mental overwork; avoidance of all psychic or emotional 
shocks; in fact, all the psychic and physical means that are often 
so effective in re-establishing nervous equilibrium, must be em- 
ployed. The results from this treatment, the exact arrangement 
of which must needs vary according to the peculiarities of each 
individual case, the surroundings, the state of life of the patient, 
are generally very satisfactory, although, as a rule, not per- 
manent. 

The most effective means of producing evacuation of the To produce 
mucus is by irrigation of the bowel with warm water or with a thT^mucus ° 
normal salt solution containing from 6 to 8 grammes of sodium 
chloride to the litre, or sodium bicarbonate solution containing 
five parts to the litre, 



602 



DISEASES OF THE INTESTINE AND PERITONEUM 



Oil injections 



Combined oil 
and water in- 
jections 



The pain 
Opium 



Hot applica- 
tions 



Hot bath 
Laxatives 



Better than water irrigations are injections of warm olive oil, 
especially during the attack; fully 500 cc. should be injected in 
the manner described in the Section on Chronic Constipation. In 
cases with much pain, five to ten drops of the tincture of opium 
may be added to the latter injection. The oil should always be 
injected slowly, ten to fifteen minutes being consumed in carrying 
out the treatment. The oil probably acts by dissolving the fecal 
masses clinging to the bowel and, in this way, aids in loosening 
the mucus; if it remains in the bowel long enough (and several 
days usually elapse before all the oil is evacuated) it is decom- 
posed into oleic acid which stimulates peristalsis. Consequently 
oil injections constitute a very effective means to prevent stagnation 
of bowel contents in the colon and rectum. For the purpose of 
combating the chronic constipation, smaller quantities of oil, about 
50 to 100 cc. may be injected, daily, for a time, between the attacks, 
and in a sense as a prophylactic measure. 

Oil given in this way can to advantage be combined with a 
water irrigation in such manner that a hundred cc. of oil are emul- 
sified by beating with the yolk of an egg, and this emulsion mixed 
with half a glass of water and injected by means of a small syringe 
high into the colon through a rectal catheter; an hour later the 
bowel is irrigated with a litre of lukewarm water. The best time 
for performing this treatment is after breakfast. 

The pain during the attack can be controlled by the addition 
of opium to the oil injection or, if necessary, by the administra- 
tion of small quantities of opium by mouth in the form of five 
drops of the tincture or as an eighth of a grain of the extract 
with a two hundredth grain of atropine. Opium, belladonna or 
atropine given thus are also the best remedies for the relief of 
chronic spastic constipation; and inasmuch as the constipa- 
tion in mucous colitis, as in most other neurotic disorders, is gen- 
erally of the spastic variet}', it will be seen that opium 
is a very useful remedy in this disease. It acts presumably by 
deadening the irritability of the sensory nerves of the bowel 
and hence preventing the reflex spasticity of the intestinal mus- 
cularis. 

During the attack the pain can also be controlled to some 
extent by the application, externally, of hot cloths or turpentine 
stupes, hot poultices or a Leiter coil charged with hot water. Im- 
mersion of the patient in a warm full bath or a sitz bath is also 
an exceedingly useful measure to reduce the severity of the pain 
and to abort the attacks. Laxative remedies are very rarely indi- 
cated in this disease. In the spastic type of constipation they 
do very little good and in the atonic type (see infra) they are 
generally superfluous; for constipation of the latter variety can 



DISEASES OF THE INTESTINE' AND PERITONEUM 603 

usually be corrected by dietetic and mechanical means alone. An 
occasional dose of castor oil or of calomel, or here and there one 
of the mild vegetable purgatives like cascara, rhubarb or senna, 
may become necessary in order to promote the evacuation of large 
accumulations of feces. All of these elements of the treatment, as 
well as the advisability of "educating" the bowel by insist- 
ing on an attempt at stool at a certain time of the day, 
suppressing the stool during others (a method of treatment that 
better than anything else aids in restoring the normal automatism 
of defecation) will be found described in the Section on 
Constipation. 

The diet, in cases of mucous colitis, should contain an abund- Diet 
ance of coarse, indigestible particles, i. e., plenty of fresh fruit 
and fresh vegetables, coarse bread and cereals containing cellu- Coarse, bulky 
lose, in other words, foods containing husks, pips, seeds, stems, 
skins, kernels, etc. The addition of two or three tablespoonfuls of 
bran to one of the breakfast foods is a very practical means of ful- 
filling this postulate. 

In addition plenty of fat in the form of cream, butter, olive Fats 
oil in salad dressing, or in mayonnaise, bacon, sardines, meat fat, 
should be given; or the patient may be ordered to take two or 
three tablespoonfuls of pure olive oil once or twice a day. 

Occasionally the sudden transition from a bland mixed diet Sudden change 
to a diet containing abundant cellulose and indigestible particles 
and much fat, aids materially in preventing attacks of mucous 
colitis and even in curing the disease. A diet, such as the one de- 
scribed, is of necessity bulky and fatty, at the same time flurry 
and aerated on account of the formation of C0 2 and CH 4 from 
the fermentation of the fruit acids and the cellulose that are in- 
gested. That meats, eggs and all other foods, that leave a small 
residue, should be correspondingly reduced and only given in 
such quantities as are necessary to adequately nourish the patient 
and supply his demands for albumen, need hardly be em- 
phasized. 

In cases suffering from entero- and gastro-ptosis, the wearing Abdominal 
of an abdominal binder or bandages to support the abdominal in ers 
walls, or a fattening cure may materially aid. 



CHRONIC CONSTIPATION. 

There are several types of constipation and each requires spe- 
cial treatment. Before undertaking to manage a case of consti- 
pation a variety of factors must, therefore, be determined and, 
on the basis of this preliminary study, the plan of treatment ar- 
ranged. 



604 



DISEASES OF THE INTESTINE AND PERITONEUM 



Physiological 
constipation 



Alimentary 
constipation 



Constipating 
effect of meat, 
eggs, milk 



Laxative effect 
of fruits and 
vegetables 



Laxative action 
of sugars and 
starches 



In the first place it is important to recognize that many people 
evacuate the bowel contents only once in two or three days, or even 
at longer intervals, throughout their life time with no discomfort 
or any detriment from this habit. This condition of constipation 
must, therefore, be considered physiologic and if no morbid cause 
can be discovered and no untoward symptoms make their appear- 
ance, that are attributable to the infrequent bowel evacuations, 
then this form of constipation is negligible and no special treatment 
is called for. It must be remembered that the peculiar mechanism 
that at regular intervals, in most people once in twenty-four hours, 
propels the contents of the colon and sigmoid into the ampulla of 
the rectum and thereby produces the peculiar sensation that leads 
to the act of defecation (in pathological cases, tenesmus) is alto- 
gether automatic and that this automatism may very well vary in 
different subjects. Here habit, or what may be called "education," 
plays an important role; or there may be a congenital element that 
determines less frequent relief of the automatic mechanism that 
in most people occurs once a day. 

There is a second form of constipation that is, in a sense, 
also physiologic and that may be called alimentary constipation. 
Here daily evacuation of the bowels occurs, but the stools are 
small and very solid. This form is readily corrected by the ad- 
ministration of the proper diet containing abundant vegetable, 
fat and carbohydrate material and relatively little albuminous 
food. 

For meat, eggs, and milk, the chief representatives of the 
albuminous foods, are so thoroughly disassimilated in the stom- 
ach and the bowel that they leave a very small residue; moreover, 
they incorporate only a small proportion of indigestible mate- 
rial and hence produce a small amount of feces; finally, very few 
chemical bodies are contained in albuminous food and few are 
formed in the bowel from their disassimilation that can stimulate 
peristalsis. 

Vegetables and fruits, on the other hand, contain abundant 
indigestible cellulose material, skins, pips, seeds, husks, stems, 
etc., that leave a large and bulky residue and also mechanically 
irritate the bowel wall to increased peristaltic action. In addi- 
tion, the organic acids and other salts that most fruits and vege- 
tables contain, furnish material for the development of C0 2 in 
the bowel by the action of intestinal bacteria and this gas, aside 
from rendering the stools fluffy, accelerates the peristaltic move- 
ments of the bowel. 

The sugar, finally, contained in fruits and vegetables, or formed 
from the starches contained in these products, is also promptly 
decomposed into C0 2 and CH 4 , and these gases again render the 



DISEASES OF THE INTESTINE AND PERITONEUM 605 

stools voluminous and stimulate peristalsis. Sugar^ moreover, on 
account of its hygroscopic properties, prevents the absorption of 
water from the bowel and hence aids in maintaining a liquid or 
pultaceous character of the stools. 

Fats act as laxatives both by lubricating the wall of the intes- Laxative action 
tine, hence rendering the propulsion of the bowel contents easier ° a s 
and, by favoring the formation of various acid bodies, soaps and 
glycerin, in the bowel, all of which possess laxative and peristalsis — 
stimulating properties. 

A diet, therefore, like that described above, usually produces 
copious stools in alimentary constipation and no further treatment 
of this condition is, as a rule, required. 

There are, however, some forms of constipation in which such Varieties of 
a diet does not produce the desired effect. There are, to begin constipation in 
with, varieties of constipation that are due to anatomic lesions in above diet is 
or about the bowel causing mechanical stenosis, constriction, com- contra-indi- 
pression or knuckling of the intestine, in which a bulky diet that 
stimulates peristalsis not only is of no value, but may be decidedly 
detrimental. To the same category belong cases of venous engorge- 
ment of the bowel wall, occurring in heart disease, and portal 
stasis, in which over-loading the bowel and irritating its mucosa 
is decidedly dangerous, as already mentioned in another section. 
In many gastric disorders, or in chronic intestinal catarrh accom- 
panied by constipation, such a diet again is distinctly contra-indi- 
cated. In all these forms of chronic constipation the underlying 
anatomic cause must, therefore, be carefully sought for and a diet 
arranged according to the nature of the primary lesion that pro- 
duces the constipation. The principles that should govern this 
selection I have described in other places. In this variety of con- 
stipation the evacuation of bowel contents must, in many instances, 
be promoted artificially by means to be presently discussed. 

All the types of constipation mentioned in the preceding para- 
graphs, must be considered either as physiological or as secondary 
to different disorders. In addition many cases of primary, habitual Primary habit- 
constipation occur and they form the proper subject of this sec- J 1 .* constipa- 
tion. 

Here it is important to determine whether one is dealing sim- Atonic and 
ply with insufficiency of the intestinal musculature (usually as- spastic constipa- 
sociated with secretory anomalies) or with spasticity of the bowel 
muscles. 

The spastic form of constipation usually develops on the basis Spastic consti- 

of various functional disorders of the nervous system, notably P atl0n 

neurasthenia and hysteria, also in certain organic disorders of the 

cerebo-spinal axis and, finally, in certain forms of intoxication, 

. Causal treat- 

chiefly by lead. Causal treatment of this form of constipation men t 



606 



DISEASES OF THE INTESTINE AND PERITONEUM 



Symptomatic 
treatment 

Opium and bel- 
ladonna 



Atonic con- 
stipation 

Uses and 
abuses of veg- 
etable-fat diet 



Additions to 
above diet 



must be directed primarily against the organic lesions of the brain 
or cord, that are frequently of syphilitic origin and hence may call 
for antiluetic medication, or against the poison that produces the 
bowel spasticity. In the purely neurotic form the same general 
hygienic, hydrotherapeutic, electrotherapeutic and psychic mea- 
sures that have been described at length in the Section on the 
Gastric Neuroses, can be applied, and the results obtained from 
this therapy are generally satisfactory. 

If it is impossible to remove the primary cause, symptomatic 
treatment must be attempted. Here the sovereign remedies are 
opium and belladonna, both drugs that reduce the sensibility of 
the gastric mucosa and, in this way, reduce the reflex spasticity 
of the bowel wall. Paradoxical as it may sound, therefore, opi- 
um, which, as presently will be shown, is one of the chief reme- 
dies in the treatment of diarrhea, becomes in this class of cases 
the most important means of relieving constipation. Laxative 
remedies, massage, irrigation of the bowel, all measures that are 
exceedingly useful in the atonic form of constipation to be pres- 
ently discussed, are directly harmful in this variety. 

Whereas spastic constipation is a comparatively rare disor- 
der, the atonic variety, which is characterized by weakness of 
the bowel musculature, is very frequent and probably constitutes 
the majority of the cases of habitual constipation that are en- 
countered in practice. 

In atonic constipation, as in the alimentary variety, the ad- 
ministration of a vegetarian fat diet generally produces relief. 
This regime should, however, be instituted with some care and 
conservatism; for, in rare instances, it will be found that the re- 
lief obtained from the institution of such a diet is not permanent, 
and that after a few free defecations, the bowels become consti- 
pated again. This phenomenon must generally be attributed to 
habituation of the bowel wall to the mechanical and chemical 
irritation of such a diet, so that the atonic musculature of the 
bowel after a short time refuses to respond to the stimulus that, 
in the beginning, incited it to increased contractions and forcible 
propulsion onward of the voluminous contents. If this sequence 
of events occurs, then it is wrong to persist in the use of the veg- 
etable-fat diet; for the latter will stagnate in the bowel and in- 
jure the atonic bowel wall both by its bulk and by the irritation 
that emanates from acid and gaseous fermentative decomposition 
products that form from the stagnating material. In such a 
case the evacuation of the bowel contents must, in the beginning, 
often be promoted by other than dietetic means. 

If it is found, however, that, in favorable cases, the diet de- 
scribed above continues to produce copious daily stools, then there 



DISEASES OF THE INTESTINE AND -PERITONEUM 607 

may be added to this diet salt foods of different kinds, i. e., Salt foods 
salt meat, salt fish; for the sodium chloride that these articles 
contain draws water into the bowel, or at least, like sugar, pre- 
vents the absorption of a certain proportion of the water from 
the bowel. This self-evidently promotes the liquefaction of the 
bowel contents. In order to further render the stools soft and Abundant 
pultaceous abundant liquid should, by all means, be ingested. water 
Cold, plain water or, better still, cold aerated, i. e., carbonated, 
beverages are very useful and a glass of cold soda water or of 
plain water, taken on an empty stomach, is, in many instances, 
an efficient means to stimulate defecation. Beer, kephyr, sour Beverages con- 
milk and similar beverages containing yeast cells, are also par- S"g ng yeast 
ticularly useful; for they aid in the formation of carbon dioxide 
in the bowel from the starchy or sweet pabulum that, as stated 
above, should be administered in abundant quantities. Fruits Juicy fruits 
containing abundant water, especially, therefore, melons, juicy 
pears, apples, peaches, plums, are also valuable in this condition 
and constitute a very convenient means of introducing large 
quantities of liquid together with sugar and fruit acids and a 
certain amount of indigestible cellulose residue. Coffee, in most 
cases of this kind, acts as a laxative. Tea, on the other hand, Coffee and tea 
and claret, on account of the tannic acid they contain, as well Claret 
as chocolate and cocoa, are less useful, in fact, have a tendency Chocolate 
to constipate. Milk, in the majority of people, produces a con- Milk 
stipating effect. In others, again, it produces diarrhea. Gruels, Gruels 
if the coarse particles are strained off, also constipate and should 
hence be avoided. 

It is necessary, therefore, as will be seen, to experiment a 
little in each case with different articles of food and drink, finally 
selecting a permanent dietary for these cases from the articles 
that are known to produce the desired laxative effect in each par- 
ticular individual. It may be added in parenthesis that smoking Smoking 
a cigarette after breakfast often aids in stimulating peristalsis 
and procuring a good bowel movement. 

An important element in the cure of atonic constipation is Education 
the education of the patient. An attempt at stool should be made 
at some regular time, preferably a little while after breakfast, 
and if the attempt is abortive for a few days, or if no desire for 
stool is experienced at this time, the effort should, nevertheless, 
be persisted in. On the other hand, the desire for stool at other 
times of the day should be suppressed; for, in this way a suffi- 
cient amount of fecal residue is allowed to accumulate for expul- 
sion at the proper time. 

Massage of the bowel and abdomen is a very important aid Massage 
to the treatment. The main objects of massage are to stimulate 



608 



DISEASES OF THE INTESTINE AND PERITONEUM 



Self-massage 



Hydrotherapy 



Cold sitz 
baths 



the peristalsis of the bowel, especially of the large intestine, and 
to mechanically propel the bowel contents onward by forcibly 
kneading and compressing the colon. In order to be effective 
this massage treatment should, for a few weeks in the beginning, 
be carried on daily. It is best conducted in an institution in 
combination with proper hydrotherapeutic means and then, for 
many months afterwards, two or three times a week at home. In- 
asmuch as general abdominal massage, in order to be effective, 
should only be performed by a specially trained expert, and as 
the technique of massage cannot be learned from a verbal de- 
scription, it need not be outlined in this volume. 

A very simple means of self-massage, that I have found high- 
ly effective, is to roll a large wooden ball, of about five or six 
inches in diameter, over the abdomen for five or ten minutes 
every morning. The patient should lie on his back with the 
knees drawn up and should breathe with his mouth open in order 
to relax the abdominal muscles as much as possible. The ball is 
then placed in the right ileo-cecal region and under slight pres- 
sure gradually rolled around the abdomen following the course 
of the colon to the left inguinal region, and then back again to 
the right inguinal region. 

Of hydrotherapeutic measures, aside from those employed for 
the cure of the general neurasthenic or hysteric condition that 
so frequently underlies the atonic as well as the spastic form of 
constipation, the following measures are of particular use in over- 
coming constipation due to atony or abdominal congestion. 

Sitz baths are probably the best measures of all. If they are 
given cold, their first effect is to drive the blood away from the 
abdomen to the upper extremities. Very soon a reactive back 
flow of blood into the abdominal vessels occurs with a resulting 
hyperemia of the bowel wall. This back flow becomes sensible to 
the patient by a feeling of warmth. The reactive hyperemia 
produced in this way is beneficial, inasmuch as it improves the 
nutrition of the bowel musculature and hence aids in overcoming 
muscular atony. A cold sitz bath should last not longer than 
five to six minutes. If the patient leaves the cold water at the 
expiration of this time, the hyperemic effect is prolonged, where- 
as, if the patient remains in the water longer, a secondary condi- 
tion of anemia occurs. 

This secondary anemia can be utilized to advantage in catarrhal 
disease of the bowel in which it is desired precisely to reduce the 
hyperemia of the intestinal wall. Here, cold sitz baths carried 
out for fifteen to twenty minutes are more useful than short ones 
and exercise a good effect upon the constipation that not infre- 
quently accompanies chronic intestinal catarrh. The effect of 



DISEASES OF THE INTESTINE AND PERITONEUM 609 

cold sitz baths can be enforced by having the patient vigorously 

rub the abdomen, legs and back while immersed in the water. 

The best time for giving the sitz bath treatment is late in the 

afternoon about an hour before the evening meal. Hot sitz baths Hot sitz bathg 

lasting five to fifteen minutes are also useful inasmuch as they 

stimulate the whole digestive tract. Their mode of action is not 

so clearly understood as that of the cold baths, and the latter are 

by far more efficacious in overcoming atonic constipation. 

Douching of the abdomen is also useful. The douches should Douching the 
be cool and the water should be directed with considerable force a omen 
against the abdominal parietes. Cool douches are very stimulat- 
ing and cause contractions both of the external abdominal mus- 
cles and of the muscularis of the intestine; they combine a ther- 
mic and a mechanical effect. In strong individuals Scottish Scottish 
douches are of particular value; they consist in directing an al- ouc es 
ternating stream of hot and cold water against the abdominal 
wall. The hot stream, combined with the mechanical effect of a 
strong jet of water, causes dilatation of the superficial vessels 
and the cold stream, following immediately afterwards, produces 
a rapid contraction. This change in the calibre of the superficial 
vessels is reflected in the vessels of the internal organs (see index). 
A similar effect can often be exercised by directing a spray of ether Ether spray 
against the sides or the front of the abdomen. 

Large, cool Priesnitz compresses, especially applied during Priessnitz com- 
the night, are also of great value in overcoming atonic constipa- P resses 
tion. They are applied by wringing a linen sheet out of cold 
water, placing it all around the abdomen and covering it with a 
flannel bandage. The water gradually evaporates through the 
pores of the flannel and in the morning the compress will be 
found dry and the skin underneath slightly hyperemia In win- 
ter it is safer to rub the abdomen with alcohol and a dry towel 
before going out, if the Priesnitz compress has been applied during 
the night. 

Passive and active exercises are also useful and any of the Exercises 
simpler free-hand exercises that stimulate contractions and stretch- 
ing of the abdominal muscles and compress the liver and hence 
determine a flow of blood to the abdominal viscera, are useful. 
In institutions, Swedish movements answer the same purpose. Out- Swedish move- 
door sports of all kinds are also very helpful; for the increased ments 
respiration and deep breathing stimulated thereby favor wide 
excursions of the diaphragm and hence, in a sense, constitute a 
massage of the whole abdominal contents. 

Electricity is of some value in atonic constipation. The most Electricity 
convenient way of giving electrical treatment is to perform far- 
adization of the abdominal parietes by the aid of two large 



610 



DISEASES OF THE INTESTINE AND PERITONEUM 



Irrigation 



ene- 



Medicated 

mata 

Salt 

Glauber salt 

Soap 

Vinegar 

Castor oil and 

egg 



Glycerin 



sponge electrodes that are placed a short distance apart upon 
different parts of the abdominal! surfaces. As it is not desired 
by this faradization to produce long tetanic contractions of the 
colonic musculature, the electrodes should be constantly moved 
about, chiefly along the course of the colon, and not kept for any 
length of time in any one place. It is probable that faradization 
of the abdomen acts favorably in constipation more by causing 
vigorous contractions of the abdominal muscles than by its effect 
upon the bowel musculature itself. The galvanic current can be 
applied by the intra-rectal method. Here the same general ruleB 
apply as in the galvanic treatment of motor insufficiency of the 
stomach. A large sponge electrode should be placed upon the 
abdomen somewhere along the course of the colon, a little water is 
injected into the rectum and a rectal electrode inserted through 
a rectal tube and connected with the anode. Here weak currents 
applied only for three to five minutes are perfectly safe and 
answer all purposes. 

To mechanically clean out the colon and to stimulate peris- 
talsis of the lower bowel, irrigations are exceedingly useful; the 
colder their temperature, the more do they stimulate peristalsis. 
Ice water, however, is rarely used and in some cases hardly safe. 
Small quantities of cool water or of physiological salt solution 
injected into the colon with a high rectal tube answer all pur- 
poses. If it is desired merely to cleanse out the contents of the 
ampulla of the rectum, then lukewarm water is better than cold 
water. 

In order to increase the stimulating effect of cool irrigations 
injected into the higher portions of the large intestine, certain 
chemical irritants can be added to the irrigating fluid, for in- 
stance, common salt or Glauber salt in the strength of two table- 
spoonfuls to the pint; or soapy water may be used, or a mixture 
of equal parts of vinegar and water. A very useful irrigating 
mixture is a tablespoonful of castor oil beaten with the yolk of 
one egg and mixed with a glass of cold water. This can be in- 
jected through a high rectal tube into the colon and exercises a 
very prompt evacuating effect. 

Glycerin, on account of its hygroscopic properties, i. e., its 
power to draw water into the intestine, may be injected directly 
into the bowel by instillation. If pure glycerin irritates too 
much it should be given in watery solution in the dose of about 
two tablespoonfuls to the quart, and this mixture injected through 
an ordinary fountain syringe; or glycerin suppositories may be 
used. Soft stools are usually produced in a short time by the use 
of glycerin. 



DISEASES OF THE INTESTINE AND PERITONEUM 611 

Finally, olive oil or sweet oil in the dose of 150 to 500 cc. Oil injections 
may be injected through a high rectal tube, five to ten minutes 
being consumed in the process. Oil acts by loosening the pieces 
of feces that are firmly attached to the colon wall, it allays local 
irritation and hence spasmodic contractions of the bowel muscu- 
lature, it prevents water absorption and hence keeps the stools 
pultaceous, and it, finally, leads to the formation of oleic acid, 
which actively stimulates the peristaltic action of the colonic mus- 
culature. Even if a free evacuation of the bowels occurs after an 
oil injection, a certain quantity of the oil is usually retained, unless 
the oil injection is followed by a copious soap and water enema. 
Hence, if no water injection is given, then smaller quantities of oil 
may be injected on subsequent days. If pure oil is not retained 
well, then it may be beaten up with a yolk of egg and water, as 
described above, and five to ten drops of the tincture of opium 
added to the mixture. This irrigating emulsion is almost invari- 
ably retained without difficulty. 

The chief advantage of using these small amounts of irrigat- Small and large 
ing fluid for the purpose of stimulating local peristalsis and me- enemata 
chanically softening the stools, is that the stomach is not irritated 
by the ingestion of laxative purgatives or drastic remedies. Large 
quantities of irrigating fluid are not so safe on account of the 
inevitable stretching and relaxation of the atonic bowel that they 
produce. This detrimental effect of large enemata can to some 
extent be counteracted by using irrigations of low temperature, 
for the cool water causes contraction of the bowel musculature 
and hence neutralizes, to some extent, the mechanical stretching 
of the bowel wall. If it becomes necessary to flush out the whole 
colon, it is best to do this by means of a back flow catheter or by 
repeated small injections. The best time for irrigating the bowel 
in chronic constipation, especially if irrigations are ordered for 
daily use or several times a week, is immediately after break- 
fast. The irrigations should, by all means, always be given at 
the same time of the day. 

The haphazard and indiscreet administration of laxatives that Laxatives 
is so commonly employed in cases of chronic constipation is, in 
most cases, directly harmful to the patient and, at best, bestows 
only temporary relief. Far from curing constipation, it usually 
aggravates the condition that it is intended to correct and makes 
the patient a slave to the use of this class of drugs. 

In the spastic form of constipation, as already mentioned 
above, laxatives are rarely needed; in fact, they are usually harm- 
ful, and opium and belladonna are the proper remedies. In the 
atonic form laxatives should also be given with great care and 
in small doses. If they are given in doses large enough to 



612 



DISEASES OF THE INTESTINE AND PERITONEUM 



Choice of lax- 
ative 



Alternation 



The different 
groups of pur- 
gatives 



Mode of action 



Nomenclature 
and definition 



Saline cathar- 
tics 



produce a diarrheie stool, then a condition of constipation, as is 
well known, usually follows for several days thereafter, which 
will generally, in its turn, have to be relieved again by large 
doses of a purgative. 

After all the dietetic and mechanical means that have been 
described above fail, then it may become necessary, in rare cases, 
to resort for a time at least to the use of certain laxative drugs. 
It is impossible to predict in any one case which of the many lax- 
atives that can be employed will be effective, and it is necessary to 
experiment a little in each individual. Even if one drug is found 
to be effective for a while, then it is always a good plan to alter- 
nate from time to time with some other remedy in order to 
prevent habituation to any one laxative. That the smallest pos- 
sible doses to produce the desired effect should be administered in 
these cases need hardly be mentioned. For continued use in 
chronic constipation, either alone or, far better, in combination 
with dietetic and physical measures, I have selected a few reme- 
dies out of the immense number of laxatives that are contained 
in the Materia Medica. These are probably the least harmful and 
the most efficacious in relatively small doses. It is impossible 
to enumerate and describe the dose and administration of all the 
laxatives that are known. For this information I refer to text 
books on pharmacology. 

The vegetable purgatives, i. e., the purgative oils (castor oil, 
croton oil), anthracene purgatives (rhubarb, senna, aloes, fran- 
gulus, cascara and others) and the preparations of the jalapin 
and colocynthin group (coloeynth, podophyllum, jalap, elaterin, 
leptandra and others), all act by irritating the bowel mucosa, 
thereby stimulating peristaltic movements of the intestine and 
hastening the propulsion onward of the bowel contents. In this 
way less time is given for the absorption of water from the small 
intestine, and the stools, consequently, reach the colon in a liquid 
or pultaceous form and are promptly evacuated. It is possible 
that these remedies, also, at the same time, cause an increased 
outpouring of watery secretions into the bowel. The character 
of the stool deposited after the administration of these remedies 
will, of course, largely depend upon the dose. Small doses pro- 
duce one or two soft movements, very large doses produce pro- 
fuse, frequent watery evacuations. It is unnecessary, however, 
to retain the old classification into aperient, laxative, purgative, 
hydragogue cathartic and drastic remedies, the violence of their 
action depending largely upon the dose, not the character, of the 
drugs. 

Saline cathartics do not irritate the intestine unless given in 
very large quantities. They act chiefly by retarding the absorp- 



Diseases otf the intestine and peritoneum 



613 



tion of water from the bowel and, to some extent, by increasing 
intestinal peristalsis, more on account of their bulk, however, 
than because of any irritating action that they exercise upon the 
intestinal mucosa. In addition, they act as concentrated solu- 
tions of salts that are only slightly diffusible through the bowel 
wall into the blood, and hence, according to the laws of osmosis, 
draw water into the bowel. 

The mercurial purgatives, chiefly insoluble preparations like 
calomel (blue pill and gray powder), do not affect the stomach, 
but irritate the bowel, owing to their long sojourn there, which 
leads to their partial conversion into irritating soluble salts of 
mercury. 

In order to produce a mildly laxative effect, cascara, rhu- 
barb, aloes, podophyllin or an alkaline saline are the best reme- 
dies for continued use. If large, hard fecal masses have accumu- 
lated in the bowel, these milder remedies are very apt to produce 
griping, so that castor oil, calomel, jalap and colocynth are bet- 
ter. If the patient is in an unconscious state or in a condition of 
mania, so that no medicine can be swallowed, one or two drops 
of croton oil placed on the back of the tongue are more effective. 
In lead colic, too, with obstinate constipation, croton oil, adminis- 
tered as above, is especially useful. Combinations of the vege- 
table purgatives with salines or with bitter tonics are justly pop- 
ular. 

Cascara is best given as the fluid extract, in doses of one-half 
to one teaspoonful; or as the wine of cascara, in doses of one to 
two tablespoonfuls ; or as the dry extract, in doses of two to 
eight grains (0.1 to 0.5 gm.). It produces a mild laxative effect 
usually within twelve to eighteen hours after its administration. 
It is, therefore, eminently useful in habitual constipation that 
does not yield to other means, if given every night before re- 
tiring. 

Ehubarb and senna are both old established remedies of tried 
effect. The chief drawback to the use of rhubarb is its tendency 
to produce constipation after the evacuation of the bowel con- 
tents has been brought about. It is best, therefore, dispensed in 
combination with a saline cathartic as, for instance, in the com- 
pound rhubarb powder, twenty to sixty grains (1.3 to 4 gm.) ; or 
as the compound infusion of senna (black draught), two to four 
ounces (60 to 120 cc.) ; or as the compound mixture of senna, 
one-half to two fluid ounces (15 to 60 cc.) ; the mistura rhei et 
soda?, two to three ounces (60 to 100 cc.) ; or the syrups of rhu- 
barb or senna, in doses of one to three drachms (4 to 12 cc). 
Senna is more active than rhubarb bulk for bulk. The former 
remedy, however, as well as aloes, to be presently discussed, should 



Mercurial pur- 
gatives 



Indications for 
the use of dif- 
ferent laxatives 



Cascara 



Rhubarb and 
senna 



614 



DISEASES OF THE INTESTINE AND PERITONEUM 



Aloes 



Podophyllum 



Jalap 



Elaterium 



Sulphur 



Aperitol 



be given with considerable care in inflammatory disorders of the 
intestine, in renal inflammation and in pregnancy. 

Aloes may be given alone in the form of the extract, two to 
seven grains (0.1 to 0.6 gm.) ; or in combination with rhubarb, 
cascara or senna in pill form ; or as the pil. aloes, one to five pills 
at a dose; or as the compound laxative pill containing aloes, 
strychnine, belladona and ipecac; also as aloes contained in the 
compound extract of colocynth, the compound rhubarb pill and 
the compound tincture of benzoin. Any of these preparations are 
useful. 

Podophyllum is especially valuable for continued use in hab- 
itual constipation. It is best given in combination with bella- 
donna as the latter neutralizes, to some extent, the irritation and 
the colic sometimes produced by podophyllum. The effect of 
small doses of podophyllum does not become apparent for about 
twelve hours after its administration, so that it is best given in 
the evening before retiring. Convenient pharmaceutical prepa- 
rations of podophyllum are the pill of podophyllum, belladonna 
and capsicum (U. S. P.), and the resin of podophyllum, one- 
quarter to one grain (15 to 60 mg.) in pill form. Podophyllum 
is a remedy of varying strength and not always reliable. 

Jalap, too, is best given in pill as the resin of jalap, in doses 
of two to five grains (0.1 to 0.3 gm.) ; or as the compound jalap 
powder, in doses of fiften to sixty grains (1 to 4 gm.). 

Elaterium may be given as the triturate or the compound 
powder; the former containing one part of elaterin to nine parts 
of sugar of milk and employed in doses of one-quarter to one 
grain (15 to 60 mg.) ; the latter containing thirty-nine parts of 
sugar of milk and given in doses of one to four grains (0.06 to 
0.25 gm.). 

Neither of the last remedies should be administered continu- 
ously in habitual constipation. They are useful particularly if 
it is desired to produce a rapid evacuation of accumulated feces. 

Sulphur alone, or in combination with rhubarb, magnesia, 
er milk sugar, produces a soft, well formed stool. An equal mix- 
ture of precipitated sulphur, powdered rhubarb, sugar of milk 
and magnesia, taken in the dose of a teaspoonful with a glass of 
water every morning and evening, is one of the simplest, least 
harmful and most efficacious remedies for continued use in cases 
of chronic constipation that do not yield to the proper diet and 
to physical means, or that are due to anatomic conditions that 
demand the use of laxative remedies. 

One of the newer remedies of considerable value is aperitol. 
This is the valerianate of phenolphthalein. In contradistinction 
to the latter drug that occasionally produces serious renal irrita- 



DISEASES OF THE INTESTINE AND PERITONEUM 



615 



Regulin 






tion and attacks of abdominal pain, aperitol is non-irritating to 
the kidneys and always quite painless in its effect. In most cases 
of collapse it may be used to advantage in place of castor oil and 
it is particularly valuable in producing the first stool after surgi- 
cal procedures. The evacuations following the administration 
of aperitol are usually very watery, hence the drug is indicated 
in cases of ascites, pleuritic effusion and in certain forms of obes- 
ity and cardiac disease. 

Eegulin is an exceedingly useful remedy for overcoming 
chronic constipation. It is an agar-agar preparation that after it 
is swallowed swells up and forms a bulky and slippery stool. The 
commercial regulin comes in paper cartons with the directions 
printed on the cover and is medicated with a mild vegetable lax- 
ative. • 

A large number of saline laxatives may be employed in the Saline laxatives 
treatment of chronic constipation. It is a very difficult matter 
to choose among them. The chief members of this group that 
are employed in medicine are the sulphate of soda (Glauber salt) 
and the sulphate of magnesia (Epsom salt), both given in doses 
of thirty grains to one ounce (2 to 30 gm.) in solution, prefer- 
ably in milk. It is important that they should not be given in a 
greater concentration than about ten per cent. Phosphate of soda 
is given in doses of fifteen grains to one ounce (1 to 30 gm.),i 
in the same way as the sulphates of soda and magnesia. 
The double tartrates of potassium and sodium (Eochelle salts), 
and the citrates of potassium and magnesium, are both 
given in doses of fifteen to forty-five grains (1 to 3 gm.) in so- 
lution. The oxide and carbonate of magnesia, in doses of five to 
sixty grains (0.3 to 4 gm.) are useful administered in a powder 
sweetened with sugar of milk or in one of the combinations enu- 
merated above. 

Besides, a number of effervescent laxative salts are given. 
The best known of these is the Seidlitz powder. This is made 
up in two papers, a blue one and a white one, the former con- 
taining three parts of Eochelle salt and one part of sodium car- 
bonate, in all one hundred and sixty grains (10.4 gm.) ; the lat- 
ter containing thirty-eight grains (2.25 gm.) of tartaric acid. 
The powders are dissolved separately in water and the two solu- 
tions poured together and the whole rapidly swallowed. The 
liquor of magnesia citrate is a solution of magnesium citrate with 
an excess of citric acid and potassium bicarbonate bottled tightly; 
upon opening the bottle effervescence occurs. The dose of this 
solution is five to twelve ounces (150 to 400 cc.) . 

A great many natural mineral waters containing laxative 
salts are used. The best of these are Hunyadi Janos, Apenta 



Effervescent 
salts 



Laxative min- 
eral waters 



i 



616 



DISEASES OF THE INTESTINE AND PERITONEUM 



Hypodermic 
purgation 



Introduction of 
purgatives by 
rectum 



water or Carlsbad water. The action of these waters is due 
chiefly to the sodium or magnesium sulphate they contain. In 
addition they contain a number of inert and less active saline 
constituents. 

The attempt has been made repeatedly to induce purgation 
by the administration of remedies hypodermicajlly. The best 
remedy for this use is apocodeine, which should be given in doses 
of one-twentieth to one-tenth grain (3 to 6 mg.), dissolved in a 
little water. Besides, aloin^ cathartinic acid and citrullin have 
been used, but their administration is very painful and their ef- 
fect is inconstant. Magnesium sulphate injected in small doses 
hypodermically is the latest hypodermic purgative to be intro- 
duced. 

Finally, the administration of purgative remedies may be 
attempted by the rectal route. Colocynth in the dose of 0.1 to 
0.03 gm. ; aloin, 0.4 to 0.5 gm. ; and cathartinic acid, 0.6 gm. dis- 
solved in a little glycerin cause prompt purgation. It is prob- 
able that these remedies after they have been absorbed from the 
rectum are carried to the intestinal mucosa through the blood, 
and act in this way rather than locally. 



DIARRHEA. 



Diarrhea in in- 
testinal atony, 
stenosis and 
catarrh 



Laxative as a 
prophylactic 



Diarrhea 
gastrica 



Diarrhea, in most cases, is a symptom only of a variety of 
primary conditions, the treatment of which has already been 
discussed. Thus diarrhea from irritation of the bowel wall by 
stagnating and decomposing or poisonous (ptomains) bowel con- 
tents is a common phenomenon in bowel stenosis, in coprostasis 
and in acute or chronic catarrh of the bowel. Here treatment 
must, in all cases, be chiefly directed towards promoting prompt 
evacuation of the offending bowel contents by the administration 
of castor oil, calomel or the use of bowel irrigation as already 
fully described in the sections on these different disorders. Be- 
sides, of course, the underlying disorder must be attacked and, if 
possible, corrected. 

In diarrhea occurring in fecal stasis due to stenosis or intes- 
tinal atony, it is important, contradictory as it may seem, to give 
a slightly laxative diet rather than one that possesses constipating 
properties; for, in this way only can the accumulation of fecal 
matter that directly produces the diarrhea, effectually be fore- 
stalled. 

An important form of diarrhea (diarrhea gastrica) occasion- 
ally owes its origin to disorders of the stomach, chiefly achylia 
gastrica and motor insufficiency of the stomach or hyperacidity. 






DISEASES OF THE INTESTINE AND PERITONEUM 617 

This variety is closely related to the one mentioned above, inas- 
much as the food fails to undergo proper disassimilation in the 
stomach, and enters the bowel in an insufficiently digested or 
partially decomposed condition, and hence throws an abnormal 
amount of labor on the tryptic functions of the intestine, while, at 
the same time, irritating and overloading the canal. This over- 
taxation and irritation may become so great as to produce true 
catarrh of the bowel with diarrhea, but even before this time the 
intestine periodically gets rid of the abnormal material which it 
cannot properly assimilate by diarrheic movements. Many of 
these cases do not apparently suffer from the stomach at all, espe- 
cially if the motor power of this organ is unimpaired. At the 
same time, the primary disorder probably lies in the stomach 
alone and the treatment of the underlying gastric disorder by 
proper dietetic and medicinal means, lavage, etc., generally leads 
to a cure of the diarrhea. From this it will be seen how impor- 
tant it is in every case of chronic diarrhea of doubtful origin to 
carefully determine the state of the gastric functions and to ar- 
range treatment accordingly. 

Dyspeptic (or better dystryptic) diarrhea must be included in Diarrhea dys- 
a similar category. Here the bowel irritation, the increased peris- P e P tlca 
talsis, the very rapid propulsion of the contents of the small in- 
testine into the colon and its prompt evacuation in the stools must 
be attributed to the ingestion of food that is irriating or poisonous. 
In this variety, too, the stomach is usually, though not always, 
affected at the same time. Here, again, the chief indication for 
treatment lies in aiding Nature in its endeavor to rid the bowel 
of the irritating material; and the prompt administration of a 
dose of castor oil or of some other effective, but not too irritating, 
laxative remedy (see index) combined with cleansing of the 
lower bowel by irrigation, is the proper preliminary treatment. 
The fact that copious and frequent diarrheic stools may have 
occurred is no contra-indication to the use of such remedies; for 
much offending material will usually still be evacuated by their 
administration and the course of the disease materially shortened 
thereby. To give constipating medicines in such cases is a gross 
error (see also the Section on Acute Catarrh of the Bowel). A 
little opium and hot applications to the abdomen may in persist- 
ent cases be required as a symptomatic means to stop very severe 
abdominal pain. 

To the rarer forms of diarrhea of intra-intestinal origin, be- Diarrhea due 
long, finally, those varieties that are produced by entozoa. That ° en ozoa 
the removal of parasites is a sine qua non of successful treatment 
need hardly be mentioned. 



618 



DISEASES OF THE INTESTINE AND PERITONEUM 



Diarrhea in 
infectious dis- 
eases 



Diarrhea due 
to blood-borne 
poisons 



Specific treat- 
ment 



Diet 



Diarrhea in 
uremia 



On the borderland between diarrhea produced by the action 
of irritants affecting the bowel from within its lumen and reach- 
ing the bowel through the blood, is the diarrhea seen in a va- 
riety of infectious diseases accompanied by catarrh and ulcera- 
tion of the intestine. In some of them, notably in typhoid, small- 
pox, sepsis, erysipelas, varioloid, diphtheria, dysentery, anthrax 
and tuberculosis, it is often difficult to decide whether the diar- 
rhea is due to local irritation in the bowel and the presence of 
ulcers or to the action of blood-borne poisons. The fact that 
in typhoid, for instance, profuse diarrhea often occurs long be- 
fore ulcers are present, that, in cholera, no anatomic changes of 
the bowel are generally found despite the most profuse diarrhea, 
that in sepsis, malaria, influenza, pneumonia, similar relations are 
frequently encountered, renders it very probable that the diarrheic 
discharges in all these forms are in great part produced by the cir- 
culation of specific toxins through the bowel wall and the irrita- 
tion of the intestinal mucosa from this source. The treatment 
of this variety of diarrhea is essentially synonymous with the 
treatment of the underlying infection and, in most cases, cor- 
respondingly successful or unsuccessful. If specific remedies are 
available the diarrhea can usually promptly be checked by their 
use; thus the diarrhea of malaria and diphtheria promptly ceases, 
as a rule, unless complicated by food poisoning (diarrhea dys- 
peptica), upon the administration of quinine or the injection of 
diphtheria antitoxin. The cleaning out of a septic focus, the 
healing of the ulcers in typhoid produces the same result without 
further interference directed towards checking the diarrhea. The 
diet, in the latter form of diarrhea, need not be modified material- 
ly on account of the existence of profuse bowel discharges. What- 
ever food is proper, in consideration of the primary disease, should 
be continued, every effort being put forward to maintain the nutri- 
tion of the patient. Fat or coarse irritating foods should be 
avoided. That nourishing semi-liquid and easily digestible foods 
should be given the preference is self-evident. The ordinary fever 
diet described in the Section on Infectious Diseases of itself an- 
swers all these requirements. 

To the class of blood-borne diarrheas^ finally, belongs the diar- 
rhea of uremia. This is probably caused by the circulation of 
ammonium carbonate which has failed to undergo proper con- 
version into urea. Here, too, appropriate causal treatment di- 
rected towards restoring the function of the liver (see index) 
and promoting the renal elimination is the most important ele- 
ment. This diarrhea must be looked upon as a conservative proc- 
ess of disintoxication that it is dangerous to check by constipating 
remedies; for, if this is done, the vicarious elimination of circu- 



DISEASES OF THE INTESTINE AND PERITONEUM 



619 



lating urinary end products and of intermediary products of 
perverted metabolism that the kidneys fail to eliminate properly 
is interfered with and the patient is often seriously injured 
thereby. 

The diarrhea occurring in the course of heart disease, especial- 
ly in the stage of failing compensation, or in portal stasis, is due 
to the venous engorgement or edema of the bowel wall. Here ap- 
propriate cardio-tonic medication and the use of those means 
that can correct venous congestion and stasis in the portal cir- 
culation is the most important element of the treatment. 

In none of the forms enumerated, it will be seen, is the use of 
constipating remedies, as a rule, indicated. Occasionally opiates, 
as already mentioned, have to be administered for the sake of 
producing symptomatic relief. Opiates allay the pain and by re- 
ducing the violence of peristaltic movements check the frequency 
of the bowel discharges, place the bowel wall at rest, and, in most 
cases, materially aid in enabling the irritated, usually hyperemic, 
intestinal wall to regain its normal state. In the dyspeptic va- 
riety of diarrhea, in diarrhea due to coprostasis and in nervous 
diarrhea, to be presently discussed, opium should, however, never 
be given. Its chief sphere of usefulness lies in the treatment of 
catarrhal and infectious types of diarrhea in which the evacuation 
of the irritating bowel contents does not bring relief and in which 
the patients suffer severe pain, and the nutrition is seriously inter- 
fered with. Here opium, morphine or codeine may be given; 
opium, in the form of the extract or the tincture, is generally 
more effective than its alkaloids; for the resins contained in prep- 
arations of the crude drug favor the slower liberation and ab- 
sorption of the active principles of opium and hence grant a more 
prolonged effect in the bowel. 

One of the most efficient newer remedies for diarrhea is alma- 
tein, a synthetic product formed by the action of formaldehyde on 
hemotoxylin. It constitutes a brick-red powder that should be 
given in doses of 2 to 6 g. per diem. It is very well tolerated 
and never produces symptoms of intestinal irritation. In bac- 
terial infections of the gastric mucosa, especially in intestinal 
tuberculosis almatein is of the greatest value, especially as 
it seems to quiet increased peristaltic movements. Patients who 
have for a long time been under the influence of opiates seem to 
tolerate the withdrawal of the latter much better, if almatein is 
given in their place. It is well to begin with small doses of 0.5 
to 1 g., several times a day. 

Other anti-diarrheic remedies like bismuth, tannin preparations, 
lead acetate, silver nitrate, etc., are indicated only in definite 



Diarrhea in 
heart disease 



Remedies 



Opiates 



When opium 
should not 
be given 



Almatein 



Bismuth 
Tannin 



620 



DISEASES OF THE INTESTINE AND PERITONEUM 



Lead acetate 
Silver nitrate 

Heat 



Nervous di- 
arrhea 



Treatment of 
the neurotic 
individual 



Diet 



Alcohol 



anatomic lesions of the bowel, and their use has been discussed in 
full in the part on Acute Intestinal Catarrh. 

Heat, finally, applied to the abdomen, either in the form of 
moist stupes, poultices or cataplasms, or in the form of dry, hot 
cloths, a Leiter coil or a thermophore, or in the form of a Pries- 
nitz or a Winternitz compress is always grateful, and distinctly 
reduces the irritability of the intestine. By relieving the pain it 
materially allays the subjective distress of the patient and, at 
the same time, in most cases reduces the number of diarrheic 
discharges. In the symptomatic treatment of diarrhea, there- 
fore, immaterial what its cause, it is an invaluable adjuvant. 

There remains for discussion an interesting form of diarrhea 
that must be regarded as a neurosis of the intestine, namely, so- 
called nervous diarrhea. It may occur acutely in predisposed 
neurotic or even in otherwise normal subjects following severe 
psychic or emotional shock, or it may be a chronic recurring con- 
dition accompanying a variety of organic diseases of the nervous 
system, viz. : Exophthalmic goitre, migraine and the functional 
neuroses, hysteria and neurasthenia. In most of the cases neu- 
rotic manifestations about the vaso-motor sphere, as sudden pallor 
or flushing of the face and neck, or hot flushes, vertigo, stupor, 
palpitation, dyspnea, various psychoses appear together with the 
attack of diarrhea. Nervous symptoms do not, however, invari- 
ably accompany this form of diarrhea. If it occurs in subjects 
who present no neurotic manifestations, the diagnosis can only 
be made by exclusion; from the absence, namely, of any digestive 
disorder, from the character of the stools and the peculiar, often 
highly bizarre factors that determine the attacks. 

The treatment of nervous diarrhea in a neurotic subject con- 
sists primarily in the use of the general measures applicable to 
the treatment of any neurosis. Here change of scene, a pause in 
the daily routine, life in a resort, a rest cure, suggestive treat- 
ment and all those hydrotherapeutic and electrotherapeutic meas- 
ures that have been described in full in the Section on Gastric 
Neuroses, are applicable. In addition any possible reflex cause, 
chiefly about the sexual sphere (in some women nervous diarrhea 
occurs chiefly during the menstrual period) and in other regions of 
the body must be sought for and relieved. 

No special dietetic rules can be formulated for the treatment 
of this form of diarrhea. It will often be found that any change 
of diet is effective for a time. It is probable that here the change 
of regime, possibly following a change of doctors, exercises a 
strong suggestive effect. 

Alcohol should be used with great moderation. It is a pe- 
culiar fact, however, that in some forms of nervous diarrhea that 



DISEASES OF THE INTESTINE AND PERITONEUM 



621 



Smoking 

Rest after 
meals 



occur immediately after eating, a small glass of brandy or liquor 
is often efficacious in warding off the attack and also in prevent- 
ing the occurrence of some of the other nervous symptoms de- 
scribed above that frequently accompany the diarrhea. Smoking 
is best prohibited. Sufferers of this kind should be advised to lie 
down for half an hour or an hour after each meal, with hot ap- 
plications to the abdomen. 

Of remedies arsenic is the most popular one, but I have never Arsenic 
been convinced that it exercises any effect upon the frequency of 
the attacks. A strong suggestive effect is as frequently exercised 
by a change of medicine as by a change of diet and in some off 
the cases the administration of a bitter tonic, or of any placebo, Placebo 
is, in my experience, fully as efficacious as the administration of 
any of the remedies that are credited with healing powers in this 
disease. In very extreme cases opium may be given in order to Opium 
check the violence of the peristaltic movements, but it should 
be used with great care in chronic cases because, especially in these 
neurotic subjects, the danger of creating an opium habit must 
always be feared. Bismuth I have found to be altogether without 
effect. 

To the same category probably belongs the peculiar form of 
diarrhea that suddenly follows any exposure to cold or any chill- 
ing of the body surfaces, especially when a draft strikes the neck, 
the feet or the region between the shoulder blades. This variety 
must be looked upon as due to a vaso-motor neurosis and belongs 
to the same class as vaso-motor coryza. The morning diarrhea, 
coming on suddenly with one or several profuse watery discharges 
about four or five o'clock in the morning before the patient gets 
up or immediately when the patient gets out of bed or puts his 
feet to the floor, must be looked upon as a nervous form of diar- 
rhea, possibly of a vaso-motor origin and produced by the change 
in the temperature of the room in the early morning hours or the 
chilling of the body surfaces when the patient leaves the warm 
bed. Patients suffering from this form of diarrhea should avoid 
any sudden exposure to cold, should, for instance, never step on a 
cold floor when getting out of bed, should always wear a flannel 
binder and appropriate clothing and footwear, as described in the 
Section on Rhinitis; they can, also to advantage, undergo a hard- 
ening process, as described in the Section on Vaso-Motor Coryza. 



Diarrhea fol- 
lowing ex- 
posure to cold 



FLATULENCY (METEORISM), 



The causes that can produce this very distressing symptom are 
manifold, and in undertaking to relieve the suffering or discom- 
fort that accrues from the abnormal accumulation of gas in the 



622 



DISEASES OF THE INTESTINE AND PERITONEUM 



Meteorism due 
to decreased 
expulsion of 
gas 



Meteorism due 
to increased 
formation of 
gas 



Meteorism due 
to peculiarities 
of bacterial 
flora 



The diet 



bowel, the exact cause must be looked for and, if possible, re- 
moved. When this cannot be done, or in cases in which the deter- 
mining factor is chronic and irremediable in character, certain 
measures must be adopted that afford at least symptomatic re- 
lief. In habitual sufferers from flatulency, finally, certain pro- 
phylactic treatment can often be instituted. 

In cases of stenosis of the bowel, in which the normal pas- 
sage of gas through the intestine is mechanically interfered with; 
in cases of acute diffuse peritonitis, typhoid fever, pneumonia 
and certain other infectious diseases in which there is toxic par- 
alysis of the bowel wall; after abdominal operations, in which 
the manipulation of the intestine or the shock must be incrimi- 
nated with producing intestinal paresis ; in general intestinal atony 
in which there is not paralysis, but merely weakness of the in- 
testinal musculature; and, finally, in certain circulatory dis- 
turbances leading to venous stasis and edema of the intestinal wall, 
less gas than normally is expelled from the bowel so that it ac- 
cumulates and produces meteorism. 

In other cases, again, the bowel lumen may be open, there 
may be no muscular insufficiency and a normal or even an in- 
creased amount of gas may be expelled from the bowel, and, nev- 
ertheless, meteorism develop. In such cases flatulency is attrib- 
utable to the formation of abnormally large amounts of gas in 
the bowel. Here evidently one must assume that the intestine has 
been invaded by an exceptionally profuse or especially active 
flora of bacteria or of hyphomycetes capable of producing fermen- 
tation. To this group also belong many of the cases of flatulency 
that are seen in catarrhal disorders of the stomach and intestine 
for here the proper disassimilation of the food does not take place 
while, at the same time, the absence of the normal secretions 
renders the bowel a suitable nidus for various fermentative bac- 
teria. 

In treating meteorism, therefore, aside from attacking the 
primary cause that creates stenosis, atony or paresis of the bowel, 
the diet must, in every case, be regulated in such a Way that espe- 
cially fermentable pabulum and articles of food undergoing fer- 
mentation when eaten, i. e., containing abundant yeast cells, are 
excluded. Thus, vegetables containing much cellulose, like cab- 
bage, peas, turnips, beans, potatoes; fresh bread, cakes, sweets of 
any kind; and of beverages, fresh fermenting liquors and drinks 
containing an abundance of C0 2 , like beer, kephyr, champagne, 
aerated mineral waters, should be excluded. As milk in some sub- 
jects undergoes rapid fermentation in the bowel, it should be 
stopped if symptoms of flatulency appear after its administration. 



DISEASES OF THE INTESTINE AND PERITONEUM 



623 



Laxatives and 
carminatives 



Action of 
minatives 



ear- 



That the diet should, in addition, be regulated in such a way as 
to take into consideration the existence of a stenosis or any of the 
primary diseases that may cause intestinal atony, paresis or con- 
gestion of the bowel need hardly be emphasized. 

Provided there are no distinct contra-indications to their ad- 
ministration, laxatives and carminatives are the best remedies for 
causing expulsion of gas that has accumulated in the bowel. 
Laxative remedies, by promoting vigorous peristalsis, obviously 
aid in the propulsion of gas through the bowel, and in addition 
promptly remove any fermenting material that may be stagnating 
in the intestine. The different laxatives that can be employed 
have been fully discussed in the Section on Constipation. 

The so-called carminatives comprise a large group of volatile 
oils and of essences, spirits, waters, tinctures, extracts and infu- 
sions containing the latter. They are useful only in mild cases 
of flatulency and are best given in combination with some laxa- 
tive by mouth. Their action is! probably that of mild laxatives 
and antizymotics. Besides, by mildly irritating the mucous lining 
of the stomach and bowel they produce a pleasant sensation of 
warmth and comfort that often obscures the distress experienced 
from flatulency, consequently their administration causes consid- 
erable subjective relief; possible, too, that their strong (and 
usually agreeable) smell and taste stimulates the gastro-intestinal 
secretions and the! appetite by a nervous reflex route and hence 
aids digestion like the bitter tonics. Following the administration 
of carminatives, eructation of gas and propulsion of gas into and 
from the bowel is generally produced, and this result would indi- 
cate that they actually increase the movements of the stomach 
and intestinal peristalsis. "Whether they aid in promoting the 
absorption of intestinal gases into the blood is questionable. At 
all events, we know, clinically, that they produce marked sub- 
jective relief in most cases of flatulency and hence their adminis- 
tration can be recommended. 

The most common carminatives employed are preparations of 
cloves, anise seed, caraway seed, peppermint, cinnamon, sassafras, 
thyme, asafetida, lemon and orange peel, fennel, cardamom, nut- 
meg, ginger and many others ; or the oils themselves may be given, 
singly or combined, or in various combinations with bitter tonics 
and stomachics according to the requirements of each case. Teas 
prepared from the herbs and seeds containing these oils are also 
a very convenient household method of administering carmina- 
tives. 

In addition to laxatives and carminatives, certain remedies Remedies 
may be administered in flatulency on account of their power to intestinal gases 



Different car- 
minative reme- 
dies 



624 



DISEASES OF THE INTESTINE AND PERITONEUM 



Charcoal 



Bismuth sub- 
nitrate 



Magnesia usta 
Physostigmine 



Colonic irriga- 
tion 



Rectal tube 



Massage of the 
abdomen 



Hot applica- 
tions and lini- 
ments 



Puncture of the 
bowel 



absorb and combine intestinal gases. The chief representative 
of this group is powdered charcoal. On account of its porosity it 
possesses the power of accumulating gas in its interstices. When 
swallowed it usually holds abundant oxygen. This is liberated in 
the intestine, hastening the oxydization of decomposing material, 
while the gases of fermentation are in their turn absorbed. It 
may be administered as animal charcoal (carbo animalis) or as 
vegetable charcoal (carbo ligni) in powder form or in the form of 
compressed tablets, in doses varying from sixty to one hundred 
and twenty grains (4 to.. 8 gm.) alone or in combination with 
bismuth subnitrate or magnesium oxide. The latter remedies are 
also credited with virtues similar to those possessed by charcoal. 
They bind a certain amount of H 2 S and C0 2 chemically with the 
formation of sulphids and carbonates of bismuth and magnesium. 

Physostigmine (eserine salicylate), in the dose of a one hun- 
dred and twentieth to a sixtieth of a grain (0.0008 to 0.016 gm.) 
in pill form, or hypodermically, given two or three times a day, has 
been recommended by von Noorden for meteorism due to intes- 
tinal atony or paresis. The drug in such small doses can do no 
harm and its administration is worthy of a trial. 

Irrigation of the colon with cool enemata by stimulating per- 
istalsis often aids in the expulsion of gas from the lower bowel. 
The addition of a tablespoonful or two of some carminative water, 
or of a few drops of oil of turpentine, to the enema is often help- 
ful; or a long rectal tube may be introduced into the colon and 
kept in place for some time; in this way much gas sometimes es- 
capes. Aspirating the gas from the lower bowel with an aspir- 
ating syringe is usually superfluous. 

Gentle massage of the abdomen performed for the purpose of 
stimulating peristalsis, especially in the colon, may be practised 
to advantage, provided no contra-indications to manipulation of 
the abdomen, as stenosis, ulceration, intestinal paralysis, exist. 

Hot applications are best of all to relieve distress. Turpen- 
tine stupes may be applied and sometimes aid in producing re- 
lief. Various liniments (see index) applied to the abdomen are 
also occasionally effective in relieving the subjective distress of the 
patient until the expulsion of gas can be promoted. 

In extreme cases, and as a precarious emergency measure, 
puncture of the distended coils of the intestine with a needle tro- 
car may be attempted in order to allow the escape of some 
of the gas from the bowel. 



DISEASES OF THE INTESTINE AND PERITONEUM 



625 



INTESTINAL PARASITES.* 



Tape-worm. — Tcenia solium, Tcenia medio canellata, Bothrio- 
ceplialus latus. In the presence of gastro-intestinal catarrh, great 
debility, pronounced anemia, chronic alcoholism, serious cardiac 
or renal lesions, tape-worm cure should always be instituted with 
great care. During pregnancy, the puerperium, lactation and dur- 
ing the menstrual period, a tape-worm cure is best not instituted. 
Very little children (status thymicus!) and very old people seem 
to stand badly the rigorous treatment necessary in order to expel 
a tape-worm. 

In instituting a tape-worm cure the patient's intestine should 
be thoroughly emptied as a preliminary measure. This is accom- 
plished by practically starving the patient for twenty-four hours, 
allowing only a little milk, coffee, some- soup and plenty of water 
on the day before. The main object of this preliminary starva- 
tion is to deprive the tape-worm of the protection from the rem- 
edy he obtains if much fecal matter is present in the bowel. This 
object is further accomplished by administering a brisk purge, 
either castor oil or calomel, on the evening before the administra- 
tion of the anthelmintic^ followed in the morning by one or two 
rectal injections, provided profuse evacuations of the bowel have 
not been produced. 

Four remedies in particular are efficacious in promoting ex- 
pulsion of the tapeworm, viz. : Male fern (aspidium felix mas) ; 
pomegranate (granatum) and pelletierine, a mixture of several of 
the alkaloids of pomegranate; pumpkin seed (pepo); cusso (bray- 
era antlielmintica) . \ 

These remedies are all given on an empty stomach in the fol- 
lowing dosages: 

Male fern, as the oleo resin, in the dose of one-half to two 
fluid drachms (2 to 8 cc), or as the liquid extract, in the dose 
of forty-five to ninety drops, preferably in a gelatine capsule. One 
hour after the drug is swallowed a purge is given, either the com- 
pound infusion of senna, in doses of four ounces, or two or three 
grains of calomel, followed within an hour by a tablespoonful of 
magnesia sulphate in a glass of water. Castor oil is not so useful, 
as poisoning from aspidium seems to occur more commonly if 
castor oil is given than if one of the other purgatives is admin- 
istered. If within two or three hours after the administration 
of the purge the desired effect is not produced, a large colonic ir- 
rigation of normal salt solution should be employed; this will 
usually bring the worm away. If only links are secured, but no 



Contra-indica- 
tions to tape- 
worm cure 



Preliminary 
treatment 



Aspidium 
Granatum 
Pelletierine 
Pepo, Brayera 



Male fern 



'Amoebic Dysentery, see under Infectious Diseases. 



626 



DISEASES OF THE INTESTINE AND PERITONEUM 



Toxic 
symptoms 



Pomegranate 



Pumpkin seed 

Cusso 

After treatment 
Round worm 

Santonin 



head or heads, a second or a third irrigation should be practised. 
If this first attempt to expel the tape-worm is not successful, at 
least a week or two should be allowed to elapse before a second 
tape-worm cure is undertaken. 

Some patients become very much nauseated or even vomit 
after they have taken the medicine. This effect can often be pre- 
vented by having them lie down and chew small pieces of lemon 
or orange peel or take peppermint drops, or swallow small ice pills, 
or teaspoonful doses of ice tea or ice coffee. 

Occasionally an over dose of male fern is given. The patients 
suffer from violent colicky pains in the abdomen^ vomiting, bloody 
diarrhea, dyspnea, cardiac collapse, amaurosis, fainting spells and 
paralytic symptoms. 

The stomach and intestine should be immediately evacuated 
by means of lavage and enemas and saline laxatives; castor oil, 
however, should never be given in these cases. Analeptics, cam- 
phor oil, ether, etc., are indicated for the collapse. 

Pomegranate is best given as pelletierine in doses of two to 
four grains (0.12 to 0.25 gm.) in capsule or pill; or one to two 
ounces (32 to 64 cc.) of the decoction (decoct, granatos cortex) 
in 250 cc. of water, taken in two portions, one hour apart, may 
be given; as the latter preparation is very disagreeable and bitter 
to the taste, it is best administered together with some flavoring 
syrup. 

Pumpkin seed is given in the dose of two to three ounces 
(64-96 gm.) of the powder suspended in an emulsion or made into 
a paste with sugar, molasses or honey. 

Cusso is administered by suspending half an ounce (15 gm.) 
of the powdered flowers in water. It is not so efficacious as the 
other preparations. 

The after treatment by purging and irrigating is the same, 
immaterial which of the vermifuges is employed. 

Eound Worm. — (Ascaris lumbricoides). Here, too, as in the 
case of the tape-worm, a preliminary starvation and purgation 
treatment should be instituted. 

The most trustworthy remedy to promote the expulsion of 
round worm is santonin. This medicine is best administered in 
the form of troches (Troch. santonin IT. S. P.) ? in the dose of one 
lozenge for a child, two for an adult, each lozenge containing half 
a grain of santonin; or the remedy may be given in solution in 
castor oil, but less of the remedy seems to be absorbed from the 
stomach if given in this menstruum than if given in tablet form. 
Three or four hours afterwards an active purge should be used to 
.carry off the parasites,. 



DISEASES OF THE INTESTINE AND PERITONEUM 



627 



In patients possessing an idiosyncrasy against santonin, or in 
individuals who have taken an over dose of this drug during the 
course of a round worm cure, xanthopsia (yellow vision) and oc- 
casionally violet vision occur. The former symptom is common 
and occurring alone need cause no alarm, for it usually passes off 
quickly without any further treatment. It is best, however, to 
call the patient's attention beforehand to the possible appearance 
of this phenomenon. In severe cases of santonin poisoning, the 
skin assumes a yellowish coloration, the urine, too, is bright yel- 
low, turning purple upon the addition of an alkali. The pupils 
are dilated. There is usually dizziness, perversions of the sense 
of smell and taste, profuse salivation, nausea and vomiting, gen- 
erally headache and mild delirium, rolling of the eyes, grinding 
of the teeth, tonic and clonic spasms, occasionally coma. If death 
occurs, it is due either to suffocation or to profound exhaustion. 

The treatment consists in the energetic use of emetics, gastric 
lavage and free purgation. The spasmodic seizures should be com- 
bated by the inhalation of a little chloroform, or by the adminis- 
tration of chloral hydrate. If respiratory failure threatens, cold 
water should be dashed upon the patient and artificial respiration 
practised with rhythmic traction of the tongue and the rhythmic 
insufflation of compressed oxygen. Abundant quantities of sodium 
bicarbonate solution should be given by mouth and in extreme 
cases this remedy should be administered either subcutaneously or 
intravenously. 

Spigelia is another useful remedy to expel round worms. It 
should be given as the fluid extract, in doses of a teaspoonful (4 
cc.) to a child, two teaspoonfuls (8 cc.) to an adult, followed by 
full doses of the infusion of senna, castor oil, or magnesium sul- 
phate; or it may be administered in the form of the fluid extract 
of spigelia and senna, in three doses, of one teaspoonful each, 
given two hours apart to a child in three doses of two teaspoonfuls 
given at the same interval to an adult. 

Still another remedy that is occasionally efficacious and that 
may be mentioned for the sake of completeness, is the oil of 
chenopodium. It should be given in doses of five to ten drops 
(0.3 to 0.6 gm.) in an emulsion or on sugar followed by a purga- 
tive. 

Thread Worm. — (Oxyuris vermicularis). This parasite finds 
its chief habitat in the large intestine, especially in the rectum, 
although, as a rule, the worms are also found in the small intes- 
tine. The parasite must, therefore, be attacked both by mouth 
and by rectum. Sufferers from thread worms should, therefore, 
receive santonin or spigelia, given in the same manner and dose 



Santonin 
poisoning 



Spigelia 



Oil of cheno- 
podium 



Thread worms 



Santonin 
Spigelia 



628 



DISEASES OF THE INTESTINE AND PERITONEUM 



Infusion of 
quassia 



Vinegar 
Sublimate 
Naphthalin 
Thymol 



Pruritus ani 



Thymol 



as described above in the treatment of round worm, followed by a 
purge. In this way the parasites contained in the small intestine 
are destroyed or propelled into the large intestine where they can 
be attacked by the rectal route. 

The chief attention, however, should be directed towards rid- 
ding the lower bowel of the parasites by large medicated injec- 
tions. The best medicine of all is the infusion of quassia made by 
adding one or two ounces (32 to 64 gm.) of quassia chips to a 
pint (500 cc.) of water and injecting the whole quantity, under 
considerable pressure, after a preliminary cleansing of the bowel 
with a copious warm soap and water enema. An attempt should 
be made to hold this injection for about five minutes. In very 
little children a cotton plug may be pressed against the anus in 
order to aid the child in retaining the medicine. Generally these 
injections must be repeated a number of times and on successive 
days and frequently at intervals for weeks. Sufferers from thread 
worms should be particularly carejul to keep the hands and finger 
nails clean and free from contact with the rectum, as the para- 
sites, and especially their minute eggs, may otherwise be car- 
ried from the rectum to the mouth, and in this way reinfect the 
patient. 

Eemedies other than quassia that are employed for attacking 
the thread worms in the lower bowel are vinegar in the dose of 
two tablespoonfuls to a litre of water; corrosive sublimate 0.01 
to 100, naphthalin or thymol, each in the strength of one part to 
one hundred of olive oil. 

The violent pruritus ani that frequently tortures sufferers from 
thread worms can usually be controlled by smearing blue ointment 
around the anus or by inserting a suppository containing from 
0.1 to 0.2 gm. of blue ointment into the rectum. 

Hookworm Disease. — ( Anchylostomiasis, uncinariasis). The 
main remedies for driving off hookworm from the intes- 
tine are thymol, betanaphthol and male fern. Eucalyptus has 
been used but is less efficacious. Of the four thymol is by far the 
best and most rapid in its action, provided it is administered in the 
proper manner and in the proper dose. 

Thymol has a distinctly irritating action and it is quite toxic 
when absorbed. It has been shown that in children and in indi- 
viduals therefore weakened by hookworm, disease, the normal 
average dose should be very much reduced, not more than one- 
tenth to one-fifth being administered. If, however, a dose of 
thymol far below the maximum is given, the remaining parasites 
unfortunately become less susceptible to the drug. Even in cases 
in which some of the parasites remain behind, the nutrition of the 



DISEASES OF THE INTESTINE AND PERITONEUM 629 

patient becomes very much, improved and the hemoglobin of the 
blood increased. If such maximal doses are given at all, it is best, 
therefore, to wait for a number of weeks before administering a 
second treatment, in order to secure the advantage of the increased 
resistance on the part of the host to the invasion of the parasites 
and the possibility bestowed therewith of giving larger doses the 
second time. 

The Porto Eican commission publishes the following table of porto^Rican 
age groups with the appropriate dose of thymol to be administered Commission 
in two doses and the latter to be modified by the general condition 
and vigor of the patient rather than by the age: 

Age, years. Grains. Grams. 

Under 5 71/2 or 0.5 

From 5 to 9 15 1.0 

From 10 to 14 30 2.0 

From 15 to 19 45 3.0 

From 20 to 59 60 4.0 

Above 60 30-45 2.0 to 3.0 

In administering thymol treatment the alimentary tract should Preliminary 
be prepared in the same manner as in the administration of any 
other vermifuge. The gastro-intestinal tract should be rendered 
as empty as possible and the minimum of food administered on 
the day previous to the treatment. A compound cathartic pill 
given in the evening should be followed by a saline purge the next 
morning. 

In view of the fact that thousands of cases have been treated 
successfully by the Porto Eican commission under Stiles,* the 
following treatment advocated by this commission may be recom- 
mended. 

"At six o'clock in the morning, one-half of the dose of thymol Directions of 
is taken in flat 5-grain capsules, the finely powdered thymol being 
thoroughly mixed with one-half to one-third its bulk of milk-sugar 
to insure rapid disintegration of the mass in the stomach and in- 
testine. The patient should lie down until some time after the 
drug has passed into the intestine ; at 7 :30 or 8 a. m., a vigorous 
purge, either of magnesium sulphate or of compound cathartic 
pill, is taken. The feces from now until the day following ought 
to be collected, washed and examined for parasites, and a week 
later a fresh sample examined for eggs to make sure of the ef- 
ficiency of the method." 



*C. W. Stiles, Bull. U. 8. P. H. and M. H. S., 1910, No. 30. 



630 



DISEASES OF THE INTESTINE AND PERITONEUM 



Betanaphthol Betanaphthol is less irritating to the gastrointestinal tract than 

thymol and hence is not apt to produce the vomiting sometimes 
occasioned by the former. It has this drawback, however, that it 
seems to irritate the lower urinary passages and the genitalia, hence 
it should never be given to patients with kidney trouble. In other 
words the urine should always be carefully examined for albumen 
and renal elements in any patient in whom a betanaphthol course 
is contemplated. 

Betanaphthol is weaker in its anthelmintic action than thymol, 
hence a cure is effected more slowly and several treatments may 
have to be given before all the ova of the hookworm disappear 
from the feces. Betanaphthol is probably more safe than thymol 
in children and old people and in very debilitated subjects. The 
following scheme of treatment is recommended by W. H. Schultz:* 
The patient is placed on a liquid diet; at 3 p. m. a mild cathar- 
tic of calomel or salts is given. On the second day at 7 a. m., 1 to 
2 gm. of betanaphthol, mixed with about one-third its weight of 
milk-sugar, is given in a gelatin capsule; at 8 a. m., 1 to 2 gm. 
are given; at 11 a. m., a vigorous cathartic of salts or compound 
cathartic pill; at 12 a glass of milk and bread may be eaten, and 
after that the regular diet (Clayton, Fort). 

Male fern Male fern is a useful remedy, provided a fresh ether extract 

of the drug can be secured. Here again the digestive tract should 
be thoroughly cleansed, especially of fats. Alcohol, too^ should 
be avoided. In so far as the drug produces marked toxic symp- 
toms if too much of it is absorbed, the driving off of the parasites 
should be promoted as rapidly as possible as soon as destruction of 
the worm by the male fern has been accomplished. On account 
of the disagreeable taste of the ethereal extract of male fern, it is 
best to administer it in capsules. The following treatment is rec- 
ommended : 

On the day preceding the course a very scanty diet and nothing 
in the evening but a little broth and water, followed by a com- 
pound cathartic pill. In the morning of the next day one dram 
of the ethereal extract of male fern in a gelatin capsule every ten 
minutes until eight capsules have been taken. If after an hour no 
disagreeable general symptoms appear four more capsules should be 
given at intervals of five minutes. Two hours later active purgation 
with magnesium sulphate. At the expiration of five days the feces 
should be examined for eggs and, if ova are discovered, the same 
treatment should be repeated. 

Prophylaxis In so far as the larvse of this disease can only flourish in moist 

soil the transference of the patient to a region with a dry soil is 



*W. H. Schultz, Jour. A. M. A., Vol. LVII, No. 14. 



DISEASES OF THE INTESTINE AND PERITONEUM 



631 



very much to be advised. The general treatment in that of the 
anemia that promptly yields as a rule, with the removal of the 
cause. 

Serum therapy in this disease has given some good results. The Serum therapy 
serum is secured from sheep that are injected with the blood 
serum of patients suffering with ankylostomiasis. From 50 to 
100 cc. are taken from these patients at intervals, the serum 
allowed to separate in a cool place and the latter then heated to 
56°, in order to destroy the complement. Of this serum 25 to 
50 cc. are injected into the gluteal muscles of the sheep. The 
antitoxic serum secured in this way is injected in increasing 
doses beginning with 2 cc. up to 5 cc. deep into the gluteal and 
deltoid muscles every other second day or twice a week. The 
results obtained from this therapy have been sufficiently favorable 
in some clinics to warrant advising the course combined, needless 
to say, with the ordinary vermifuge treatment. 



THE PERITONEUM. 

ACUTE DIFFUSE PERITONITIS. 



Acute, diffuse peritonitis following intestinal perforation, pro- Perforative 



vided the patient is seen within the first ten hours after perfora- 
tion has occurred, calls for an immediate laparotomy. While an 
occasional spontaneous cure of perforative peritonitis is recorded, 
it is decidedly bad practice to count on this remote possibility and 
to refrain from an operation; for without an operation the patient 
is practically doomed, with an operation he has a chance, though a 
small one, of recovery. The earlier the operation is performed, the 
better; for in perforative peritonitis the point of perforation may 
be discovered and closed up and thus further contamination of the 
peritoneal cavity prevented ; besides, free drainage is thereby estab- 
lished and the peritoneal cavity rid of a good deal of toxic mate- 
rial. 

The preliminary shock often following perforation is no con- 
tra-indication to the operation. The development of secondary 
shock and collapse that is often seen in the latter stages of dif- 
fuse septic peritonitis, renders the outlook more precarious, but 
it does not apparently render the prognosis altogether hopeless, so 
that here, too, a laparotomy should generally be performed. 

If the symptoms of a general toxemia are not very pronounced 
and if the local symptoms about the abdomen are most prominent, 
the chances of improvement or recovery from drainage of the 
peritoneal cavity by laparotomy are not bad. 



peritonitis 



Shock no con- 
traindication 
to an operation 



632 



DISEASES OF THE INTESTINE AND PERITONEUM 



Acute diffuse 
peritonitis a 
surgical dis- 
ease 



Object and lim- 
itations of in- 
ternal treat- 
ment 



Rest 



Opiates 



Rest of the 
bowel 



Total absti- 
nence from 
food 



Opiates 



Thirst 



Acute, diffuse peritonitis, then, in the light of our present 
knowledge, is essentially a surgical disease. Internal measures 
offer very slight chances to the patient and until serum therapy 
shall have given us a remedy to combat the bacterial toxemia, the 
efforts of the medical man must be directed principally towards 
forestalling the occurrence of peritonitis and towards preventing, 
so far as that is possible, an extension of the process or an aggra- 
vation of the condition in cases that cannot be operated upon 
promptly. Finally, internal treatment should be directed to- 
wards supporting the patient's strength in every way in cases that 
cannot or will not be operated upon, in the feeble hope that spon- 
taneous recovery may after all occur. An optimistic attitude, even 
in apparently desperate cases, can assuredly do no harm, and if 
nothing more is accomplished, the unhapyy victim may at least 
be rendered comfortable and saved the excruciating tortures of 
body and mind that usually precede death from this horrible dis- 
ease. 

A patient with acute, diffuse peritonitis should be kept per- 
fectly quiet. Most cases endeavor to do this spontaneously. Here 
and there, however, the pain is so great that the sufferers thrash 
around in bed trying to find a comfortable position. In such 
cases opium or morphine may be needed to enforce quiet. The 
best position for the patient to occupy is the dorsal with the head 
of the bed elevated in order to promote drainage towards the pel- 
vic region, which is apparently more resistent to pus than other 
areas of the peritoneum. As a rule the patient will lie on his 
back with the legs drawn up. This position, if not spontaneously 
occupied, should be encouraged, and the legs, if needed, support- 
ed by pillows or by a support placed underneath the knees. 

Eest of the bowel should be secured by all means. Active 
peristaltic movements prevent closure of the perforation and seal- 
ing of the perforative opening by peritoneal adhesions, favor 
spreading of bacteria through the peritoneal cavity and, above all, 
increase the pain. Intestinal rest should be secured as described 
in detail in the Section on Circumscribed Peritonitis by a total 
abstinence from food during the first days of the disease, by re- 
fraining from the use of any laxative remedy, by avoiding rectal 
irrigations or rectal feeding and by employing opium. Opiates 
act as favorably on the subjective symptoms of the patient as in the 
circumscribed variety (dose and administration, see infra), by 
allaying the pain and by inhibiting many of the reflexes attribu- 
table to this factor, namely, vomiting, hiccup, restlessness and, to 
some extent, shock. 

Another very useful effect of the opiates, finally, in view of 
the danger in this disease of giving anything, even water, by 



DISEASES OF THE INTESTINE AND PERITONEUM 



633 



mouth, is their power to allay the distressing thirst that often 
tortures these patients. The thirst can, furthermore, be controlled 
by allowing the patients to suck small pieces of ice without per- 
mitting them to swallow the water. 

The water demands of the organism may be supplied by the 
injection of normal salt solution by hypodermoclysis or intraven- 
ously (technique, see index). Large quantities of fluid may be used 
for this purpose, as distinct advantages seem to accrue to many 
cases of diffuse peritonitis from this practice; for the blood pres- 
sure is raised thereby and the heart stimulated. It is possible, too, 
that the injection of abundant liquid under the skin and into the 
circulation dilutes the toxins and promotes their elimination from 
the body. Finally, the injection of large quantities of fluid di- 
rectly into the blood vessels prevents to some extent, the absor* 
tion of toxins from the peritoneal cavity, seems, in fact, to dt 
termine an outpouring of fluid into the peritoneal cavity. Ii 
some hospitals very large quantities, as much as ten to fifteen 
pints, of salt solution, are infused or injected in this way in every 
case of acute, diffuse peritonitis, even as a preliminary to an op- 
eration for diffuse peritonitis, and remarkably good results are 
reported from this plan. The method, therefore, is certainly 
worthy of trial, not only as a means to quench thirst 
and to maintain the water equilibrium of the body, but even as a 
curative agent. 

Very little can be expected from local applications. Neither 
continuous nor interrupted applications of cold exercise any de- 
terminable influence on the course of the disease. One must be 
guided in making applications to the abdomen by the sensations 
and the desires of the patient, and apply either heat or cold in 
that form that brings the most relief. Inunctions of the abdom- 
inal surface with gray ointment or with other counter-irritant 
salves is no longer practised. It is hard to understand how any 
measure of this kind can do good. 

For the symptomatic treatment of acute, diffuse peritonitis, 
opiates and heart tonics are the best remedies. The former, as 
stated above, relieve the pain, the restlessness, the vomiting, the 
peritoneal nerves and hence effectively counteract the tendency to 
initial collapse. 

For the vomiting, provided it is not controlled by opiates, i. e., 
either opium given by mouth or morphine administered hypoder- 
mically, a few drops of chloroform on ice or a teaspoonful of ice 
cold chloroform water or a dilute cocaine solution administered 
in frequent doses may be given. Priessnitz compresses applied to 
the epigastric region are sometimes an effective counter-irritant 
that controls the vomiting. 



Subcutaneous 
and intraven- 
ous fluid in- 
jections 



Local applica* 
tions 

Inunctions 



Symptomatic 
treatment 



Initial col- 
lapse 

Vomiting 



634 



DISEASES OF THE INTESTINE AND PERITONEUM 



Hiccup 



Meteorism 



Cardiac fail- 
ure and col- 
lapse 

Digitalis 



Adrenalin 

Analeptics 
Alcohol 



Hiccup can occasionally be controlled by small doses of atro- 
pine — a one-hundred-and-twentieth to a fortieth of a grain (0.0005 
to 0.0015 gm.), given either by mouth or hypodermically. This 
remedy is to advantage used in combination with a quarter of a 
grain (0.015 gm.) of morphine hypodermically, two or three times 
in the twenty-four hours. 

Meteorism, if it seriously interferes with respiration and the 
action of the heart by pressure upon the diaphragm, is best con- 
trolled by the insertion of a soft rubber catheter into the rectum, 
which aids the expulsion of the gases. More active measures de- 
scribed in the Section on Meteorism are hardly ever applicable. 

If signs of heart weakness or collapse appear after the disease 
has persisted for some days, if the pulse is rapid and of a low ten- 
sion, then digitalis may be given in the dose of five drops of the 
tincture every few hours. Better still is adrenalin chloride^ hy- 
podermically, in doses of ten to thirty drops of a 1:1,000 solution 
and repeated until the effect on the blood pressure becomes ap- 
parent; or adrenalin in the above dosage may be added to the 
large saline infusions that have been spoken of. In serious heart 
failure coming on suddenly the ordinary analeptics, caffein, cam- 
phor, ether, ammonia may have to be employed. Alcohol, too, ia 
the form of strong spirituous liquors, given by mouth or injected 
in dilute form into the rectum, may serve a similar purpose. Al- 
cohol seems to be particularly useful in profound sepsis that 
threatens to produce heart collapse. 



ACUTE CIRCUMSCRIBED PERITONITIS, PERITYPH- 
LITIS, APPENDICITIS. 

Classification So far as the treatment is concerned, inflammatory and sup- 

purative processes about the appendix and the peritoneum of the 
ileo-cecal region cannot very well be separated, especially as most 
cases of perityphlitis originate from appendiceal inflammation 
and as cases of appendicitis rarely run their course without some 
inflammation of the pericecal tissues. The treatment of acute 
circumscribed peritonitis in other areas of the abdomen does not 
differ from that of perityphlitis. 

Internal therapy, which essentially means an expectant plan 
of treatment with rest and the avoidance of all agencies that can 
produce local irritation, is successful in a large proportion of 
cases. In other cases surgical intervention is imperative from 
the onset of the affection. In still other cases it is good practice 
to wait for definite indications before advising surgery, and, a last, 
fortunately small group of cases, run a rapidly fatal course unin- 
fluenced in any way by internal or surgical treatment. 



DISEASES OF THE INTESTINE AND PERITONEUM 



635 



In the management of a case of appendicitis the most difficult 
task is, therefore, to determine whether to operate and when to 
operate; to decide whether it is safe to await further developments 
before placing the patient on the operating table, or whether it is 
necessary to order surgical intervention at once in order to save 
life. 

The operative treatment of appendicitis has, without doubt, re- 
duced the mortality from this disease. While the death rate 
from surgery, when the operation is performed by skilled and ex- 
perienced surgeons supported by all the facilities of a modern 
hospital, is low, the surgical death rate is far higher in country 
communities, where an operation has to be performed at the pa- 
tient's house, without trained attendants and by a general prac- 
titioner who constantly comes in contact with septic cases and 
whose experience is, of necessity, limited. Under the latter cir- 
cumstances (and in this large country of ours, conditions such 
as those described are very general), the mortality would proba- 
bly be lower if no cases were operated than if surgical interven- 
tion were practised in every case, as some surgeons advise. The 
voluminous statistics in favor of the operative treatment of ap- 
pendicitis that emanate from large surgical hospitals, and the 
arguments adduced from these statistics by the master surgeons 
operating in each of these clinics, are consequently not applicable 
to practical conditions encountered in everyday medical life in 
smaller communities. 

The following conditions by all means call for prompt surgi- 
cal intervention: 

1. Perityphlitic or appendiceal abscess. This must, of neces- 
sity, be opened and drained. It is true that spontaneous rupture 
of such an abscess through the skin or into the bowel may occur, 
but, in view of the much greater probability of such an abscess 
rupturing into the peritoneum, it is an exceedingly precarious 
matter to forego surgical treatment. 

2. Intestinal obstruction. Here surgery in most cases is the 
only means of cure. If the obstruction is due to bowel paresis 
occurring in the course of diffuse septic peritonitis, even surgery 
is in most cases unable to help and these patients die with or with- 
out an operation. 

3. Acute perforative peritonitis. Here an operation performed 
without delay is sometimes life-saving, although, even in this 
emergency, a few instances are on record in which the patient re- 
covered without an operation. 

4. Cases of diffuse peritonitis of one or two days' duration. 
These should be given the benefit of an operation; for, while 
most of these patients die even if a laparotomy is performed, the 



When to op- 
erate 



Critique of 

surgical 

statistics 



Conditions 
calling for sur- 
gical treat- 
ment 



Abscess 



Intestinal ob- 
struction 



Acute perfora- 
tive peritonitis 



Diffuse peri- 
tonitis 



636 



DISEASES OF THE INTESTINE AND PERITONEUM 



Subacute fibro- 
purulent peri- 
tonitis 



Indications for 
surgical in- 
tervention 



Temperature 



The pulse 



patient is assuredly doomed (with some doubtful exceptions that 
are scattered through the literature ) unless the abdomen is opened. 

5. Sub-acute ftbro-ptirulent peritonitis. These cases offer an 
excellent field for surgical intervention. "The majority of cases 
of diffuse peritonitis cured by surgery belong to this category." 
(Nothnagel). 

Valuable indicies to guide the physician in regard to the ad- 
visability of operative interference in cases of appendicitis and 
perityphlitis are: The course of the temperature; the fluctuations 
in the pulse rate; the pain; the fluctuations in the number of 
leucocytes and the character of the tumor. By means of these 
clinical signs the presence or absence of pus can usually be diag- 
nosed and indications for and against surgical intervention in 
general be formulated. 

The temperature, as a rule, depends on the character and the 
virulence of the bacteria causing the infection. A high temper- 
ature, i. e., 103° F. and over, persisting until or after the fourth 
day, generally indicates a virulent type of infection. A high 
temperature at the onset of the attack, even when accompanied 
by a chill, but disappearing by the end of the third day, may occur 
in simple catarrhal inflammation of the appendix and, alone, con- 
stitutes no indication for surgical intervention. Eelatively low 
temperatures of 101 or 102°, persisting after the fifth or sixth 
day of the disease, render a laparatomy advisable, especially if 
at this period the temperature, instead of gradually dropping, rises 
and fluctuates rapidly within several degrees. A rapid fall of 
the temperature at any time of the disease should put the physician 
on the alert for perforation and acute diffuse peritonitis. It is 
well to remember that sometimes a large abscess due to the pres- 
ence of bacteria that are only slightly virulent may have formed 
and the temperature still remain low or normal. Here other 
signs than the fever must be the main guide to the diagnosis and 
the low temperature self -evidently constitutes no contra-indication 
for an operation. In view of the great importance of the tem- 
perature curve in rendering a diagnosis in regard to the exact 
conditions present, it is clear that antipyretic drugs should never 
be given in appendicitis; for their administration obscures one of 
our most important clinical indices. 

A small, rapid, soft, pulse, especially when associated with a 
relatively low temperature, signs of cyanosis, cold extremities, 
cold sweats and diffuse sensitiveness over the whole abdomen is 
often indicative of acute diffuse peritonitis. A rapid, bounding, 
full pulse, on the other hand, associated with a correspondingly 
high temperature, severe and strictly localized pain, particularly 
within the first two or three days of the disease, is not necessar- 



DISEASES OF THE INTESTINE AND PERITONEUM 



637 



ily an indication for a laparotomy, and it is usually safe to treat 
such cases, under careful supervision, by internal means. A sud- 
den change in the volume and the tension of the pulse, of course, 
always constitutes a serious warning of impending danger. 

The pain is a very unreliable symptom and one that I am The pain 
in the habit of neglecting when attempting to arrive at a decision 
in regard to the advisability of operating. Especially if the 
opium treatment is employed (see below) the pain is dulled and 
this symptom eliminated from consideration altogether. More- 
over, very mild attacks of appendicitis may be accompanied by 
very severe pain, and exceedingly grave attacks by slight pain or 
no pain at all. Very much will depend on the individual sensi- 
bility of the patient, the presence or absence of much fecal mate- 
rial causing distention of the bowel and other quite uncontrollable 
elements. A vety severe sudden pain in the ileo-cecal region 
should, of course, always arouse the suspicion of a perforation. 
Gangrene of the appendix, one of the most dangerous complica- 
tions, is often accompanied by very slight pain or no pain at all; 
for "a dead appendix feels no pain." 

If the examination of the blood shows a high degree of poly- The leucocytes 
nuclear leucocytosis, increasing steadily, this generally indicates 
pus and renders a laparotomy advisable. Too much reliance 
should not, however, be placed upon this sign; for very serious 
distinctly surgical forms of appendicitis are encountered in which 
this progressive increase in the number of leucocytes does not oc- 
cur.* 

A steadily growing tumor in the ileo-cecal region, or a swell- The tumor 
ing the size of which remains stationary after the fourth or fifth 
day of the disease, especially when associated with a high, persist- 
ent fever, and an increase of the leucocytes, in most cases indicates 
an abscess and calls for surgical intervention. If leucocytosis and 
a high fever are absent, and if the tumor is not especially painful, 
a preliminary irrigation of the colon with small amounts (200 
cc.) of lukewarm water may safely be attempted and the tumor, if 
it is fecal in character, will sometimes promptly disappear under 
this treatment, the temperature drop and the meteorism vanish. 
I have never considered it safe, under any circumstances, however, 
to give an internal laxative on the suspicion that the tumor might 
be fecal in character, especially if there was much fever and a 
high leucocyte count. 

It will be seen, therefore, how exceedingly difficult it is to ar- 
rive at clean cut indications for surgical intervention in this dis- 
ease. No absolutely fixed rules for or against an operation can 

•The clinical significance of a sudden drop in the leucocytes is 
not clearly established. 



Difficulties of 
arriving at a 
decision 



638 



DISEASES OF THE INTESTINE AND PERITONEUM 






Advantages 
and disadvan- 
tages of surgi- 
cal and medi- 
cal treatment 



Internal treat- 
ment 



Rest of the 
patient 



Rest of the in- 
testine 
Abstinence 
from food 
Thirst 



be set down, and each case must be judged separately. On the 
one hand, as stated above, an apparently simple case may lead to 
perforation or gangrenous rupture of the appendix with acute 
peritonitis ; on the other, an apparently very severe case may prog- 
ress toward complete resolution without surgical intervention. 
Here and there a case would have been saved had an operation 
been performed at once. Here and there, on the contrary, a case 
would have lived had operative interference not been attempted, 
for the administration of an anesthetic, the excitement, the fear 
and the shock of an operation, not to speak of the difficult 
manipulation of an inflamed, or adherent or fragile appendix or 
cecum, are by no means negligible elements. If the case, more- 
over, heals without an operation,, convalescence is more rapid and 
there remain nonei of the disagreeable sequelae of fecal fistula, 
broad adhesions, etc., that may follow any laparotomy performed 
during the acute stage of appendicitis or perityphlitis. I am in- 
clined to the belief that more cases are destroyed by unnecessary 
surgical intervention, especially in country practice, than would be 
sacrificed for lack of an operation, particularly if the proper inter- 
nal treatment to be now described is instituted and the patient is 
very carefully watched all the time for the appearance of definite 
surgical indications. 

Complete rest of the patient is one of the most important ele- 
ments of the treatment. The patient should remain on his back 
with the right leg drawn up and preferably supported under the 
knee by a pillow or two ; the body should be slightly raised or the 
whole head of the bed elevated; in this way drainage into the pel- 
vis is promoted in case perforation should occur. This is an im- 
portant element, because ,the pelvic peritoneum, especially in 
women, is singuarly resistent to pus infection. The patient should 
not be allowed to get up under any circumstances, nor should he 
be permitted to perform any violent movements in bed. Defeca- 
tion and urination should be performed with the aid of the bed 
pan and the urinal, and the patient should be lifted upon the bed 
pan by attendants and not allowed to raise himself. The patient 
should remain in bed for at least five to ten days after the disap- 
pearance of all acute symptoms, the fever and local signs. If 
these precautions are not carried out, delicate peritoneal adhesions 
that are thrown out in the inflamed area are apt to be torn and 
dangerous complications engendered thereby. 

The intestine, too, should be placed completely at rest. If 
there is nausea or vomiting, complete abstinence from food for 
one, two or three days is a very good plan. As the patients gen- 
erally become very thirsty under this total abstinence, small pieces 
of ice may be sucked or the mouth may be frequently rinsed with 



DISEASES OF THE INTESTINE AND PERITONEUM 



639 



some antiseptic solution, a little peppermint water or soda water, 
or the patient may be allowed to chew a little gum. In some cases 
water, given in teaspoonful doses every hour or so, can, however, 
do no harm, as all of the water is absorbed in the stomach or in 
the first part of the intestine, and as the ingestion of water only 
very slightly stimulates bowel peristalsis. 

After forty-eight hours, provided there is no more vomiting, 
a little milk, in doses of a tablespoonful or two, may be adminis- 
tered every two or three hours, or a little meat broth with an egg 
stirred into it, or some thin, strained gruel made of boiled milk 
and barley, wheat, oatmeal flour or sago, arrowroot, tapioca may 
be permitted in small doses. If milk is distasteful to the patient 
or is not well borne, especially if it produces flatulency, it should 
be stopped and gruel made of water and the above flours, soups 
and broths alone should be given. 

After a week or ten days, provided all acute symptoms have 
disappeared, a soft boiled egg, some mashed potatoes, some vege- 
table purees, a little very finely chopped sweetbreads, chicken or 
mutton, may be administered, and, then, very gradually, a solid 
mixed diet resumed, omitting all those articles from the bill of 
fare that contain spices or condiments, that produce much fer- 
mentation in the bowel or that leave a coarse, indigestible resi- 
due. 

Nutritive enemata are rarely required and best avoided alto- 
gether. The injection of lukewarm water into the lower bowel 
for the purpose of supplying some water to the body is rarely 
necessary during the first few days, especially if the patient is 
allowed' to take a little water by mouth, as indicated above; in 
fact, the injection of fluids into the rectum is, in most cases, a 
somewhat precarious procedure and one that is best avoided. 
Later in the disease and under the conditions outlined in an- 
other paragraph, injections of small quantities of lukewarm wa- 
ter given for the purpose of dissolving fecal masses in the colon 
and cecum may be administered and an ileo-cecal tumor due to 
fecal accumulation may sometimes be caused to disappear thereby. 

In order to bestow complete rest upon the intestine the sov- 
ereign remedy is opium. Many surgeons object to its use in this 
disease as well as in intestinal occlusion, on the ground that it 
obscures symptoms, causes valuable time to be lost, lulls the pa- 
tient and the physician into a sense of false security. These ob- 
jections are invalid if the temperature, the pulse, the leucocytes 
and changes in the tumor are carefully watched. The pain, it is 
true, is obscured, but, as indicated above, this symptom is the 
least important of all the signs of appendicitis and perityphlitis, 
the least constant and the least reliable index of the actual condi- 



Diet during 
first days 



Diet after 
week 



Nutritive ene- 
mata and 
bowel irriga- 
tion 



Opium 



Objections to 
opium 



640 



DISEASES OF THE INTESTINE AND PERITONEUM 



Advantages of 
opium 



Effect on pain, 
vomiting, nau- 
sea, thirst 



Dose 



tions existing. Under opium the local rigor of the abdominal 
muscles becomes much less intense, and palpation of the tumor 
or its recognition, as the disease progresses, much easier. This is 
very important from the standpoint of diagnosis and for the pur- 
pose of determining the exact time of an operation should surgical 
intervention become necessary. 

Unless one accepts the standpoint, therefore, that every case 
of appendicitis or perityphlitis should be treated surgically, opi- 
um is a most useful adjuvant to the treatment; for it effectu- 
ally inhibits peristalsis and hence materially reduces the danger 
of perforation and extension of the process to larger areas of the 
adjacent peritoneal coverings. Opium, too, if properly adminis- 
tered, stops the vomiting and the nausea and by constipating the 
patient renders defecation unnecessary. These are all advantages 
inasmuch as they prevent periodical increase of the abdominal 
pressure and, above all, the necessity of the patient sitting up in 
order to vomit or to deposit the stools. Lastly opium aids in re- 
ducing the sensation of thirsty not to speak of its quieting effect 
on the patient's mind. 

The dosage should be regulated chiefly by the sensation of 
the sufferer. Just enough and not more should be given to stop 
the pain and to keep the patient comfortable. When the pain 
disappears, opium should be discontinued, only to be adminis- 
tered again when the pain reappears. If no pain is present or 
if it is minimal, one can get along very well with very little opium. 
If there is no gastric irritation with nausea and vomiting, tincture 
of opium may be given by mouth in the dose of five to ten drops 
in a little water every two hours until the desired effect is pro- 
duced. If there is vomiting or nausea, opium is better given in 
suppository in two or three doses of one-half grain (0.1 gm.) of 
the extract, or, finally, if neither method is well borne, opium 
may be given hypodermically in the following preparation : 



Extract! opii liq., 
Water, 



1 
20 



This amount may be injected two or three times a day. The 
solution should be freshly prepared and injected subcutaneously 
with particular aseptic precautions. Morphine, in the dose of a 
quarter to a half grain (0.015 to 0.03 gm.) may sometimes have 
to be given in place of opium, twice or three times a day, hypo- 
dermically. Opium, however, is far better than morphine, as it 
is much more effective in inhibiting intestinal peristalsis than 
morphine. Whenever feasible, opium in the form of the tincture 
or the extract should be given by mouth, 



DISEASES OF THE INTESTINE AND PERITONEUM 



641 



The opium treatment should be continued for about a week 
after the acute symptoms have disappeared. The constipation 
that results from the opium treatment is negligible, even if there 
are no bowel movements for six or seven days^ especially as no 
food, leaving a residue, is eaten. Even if no opium is taken no 
attempt should be made to move the bowel by laxatives. When 
the time has come for cleansing out the bowels gentle irrigation 
should be practised, but no purgatives should be administered. 

Formerly when the belief was prevalent that appendicitis was 
due to fecal accumulation (stercoral typhlitis) purging was gen- 
erally resorted to throughout the course of the disease, and I have 
no doubt that much serious harm was done in that way. There 
is too great a tendency on the part of the patients and often the 
physician to insist on a bowel evacuation every day; and possibly 
one of the most difficult tasks that the practitioner is confronted 
with is to convince the patient and, above all, his friends, that no 
harm can arise from locking the bowels for a week if necessary 
in these cases, and I quote no less authority than Nothnagel in 
support of this view : "Even constipation lasting for a week is use- 
ful and does no harm/' 

Of local measures the ice bag is the best in most cases. If 
the weight of even a small bag is disagreeable to the patient, the 
ice bag may be supported from a string, stretched from the head 
to the foot of the bed, so that the bag gently rests over the ap- 
pendiceal region. One of the great advantages of this plan is 
that the patient must keep perfectly quiet in order to hold the ice 
bag in place. Some local treatment should, in every case, be in- 
stitued if for no other reason than to convince the patient that 
something active is being done for him, and the quieting psychic 
effect of an ice bag cannot be overestimated. Some patients feel 
better with a hot water bag or hot compresses, but I prefer cold 
throughout; at least, by all means, for the first five days. If cold 
is very disagreeable, and some patients, it will be found ; complain 
bitterly of cold, cool Priesnitz compresses or a Leiter coil charged 
with cool water may be used instead. After the most acute symp- 
toms of the disease are over, heat may be applied in the form of 
hot poultices, a Leiter coil charged with hot water, large Priesnitz 
compresses or a Winternitz compress (see index). It is very 
doubtful whether heat exercises any determinable effect on the ab- 
sorption of perityphlitic exudates. 

Other local measures are of very little value. Counter-irri- 
tants, blistering, painting with iodine, leeching, etc., are best 
eschewed. They do no good in so far as affecting the process is 
concerned. Occasionally they relieve the pain somewhat, but this 
property need not be utilized when the opium treatment is being 



Duration of 
opium treat- 
ment 

Constipation 
negligible 



Danger of 
purging 



Local measures 
Ice bag 



Hot applica- 
tions 



Priessnitz 
compress 
Leiter coil 



Counter-irri- 
tants to be 
avoided 



642 



DISEASES OF THE INTESTINE AND PERITONEUM 



Hydrotherapy 
to be avoided 



Massage to be 
condemned 



After treat- 
ment 

Diet 

Colonic flush- 
ings 



Avoidance of 
violent exercise 



The interval 
operation 



Advantages of 
interval oper- 
ation 



instituted. The chief disadvantage accruing from their use is 
that they injure the skin and hence render greater the possibili- 
ties of stitch abscesses, or even deeper pus infections in case an 
operation becomes necessary. 

Bathing or other hydrotherapeutic measures are distinctly 
harmful during the acute stage of the disease; for, during the 
first few days, absolute rest is the prime requisite. A sponge 
bath gently administered in bed, sponging each extremity sepa- 
rately with soap and tepid water for purposes of cleanliness, can 
do no harm, but even this is best omitted during the first few 
days. For reducing the temperature, cool sponging is never to 
be instituted in this disease, as no attempt should be made to re- 
duce or modify the temperature, because temperature fluctua- 
tions are one of our chief indices of the course of the disease and 
the advisability of operating. 

That massage of the appendiceal region should never be per- 
formed during the acute stage need hardly be emphasized. Just 
what one might expect to accomplish thereby it is difficult to un- 
derstand. The proceding is quite commonly followed, but must 
be condemned as immensely dangerous. During convalescence it 
is altogether superfluous and generally fraught with danger; for 
the fine peritoneal adhesions that act as a protective cover- 
ing over the inflamed area are very apt to be torn by manipula- 
tion from without. I do not believe that the absorption of large 
masses of exudate even later in the disease is in any way hastened 
by abdominal massage. 

The after treatment of peritonitis and perityphlitis must con- 
cern itself chiefly with an attempt to prevent a recurrence of 
acute attacks. The diet should be regulated in such a way that 
no irritating or indigestible foods are eaten. In order to prevent 
fecal stagnation in the cecum, bi-weekly high colonic flushings 
and an occasional dose of castor oil may be given, although it is 
well known that free daily bowel movements by no means pre- 
vent the recurrence of appendicitis. Particular care should be 
taken not to indulge in violent exercise of any kind. The patient 
should lead a quiet life and should indulge in no out-door sports. 
Massage of the abdomen, as stated above, should be forbidden. 

Despite all these precautionary measures recurrences appear 
in a certain proportion of the cases, so that one must always 
think of the advisability of an operation for the removal of the 
appendix after the first or subsequent attacks. 

Wheras an operation during the acute stage must always be 
considered an emergency measure and one that is never devoid 
of danger, the interval operation, which is becoming deservedly 
popular, may be regarded as a conservative surgical inroad and 



DISEASES OF THE INTESTINE AND PERITONEUM 



643 



one of the safest operations. Moreover, it constitutes the most ef- 
fective and, in many cases, the only means of preventing the re- 
currence of attacks of appendicitis. Nevertheless, even this opera- 
tion should not be advised as a routine measure, for there is noth- 
ing more horrible to contemplate in the retrospect than the death 
of an apparently healthy individual from an anesthetic or from 
shock or from some unforeseen complication that may arise in the 
course of an operation in which the appendix is removed as a 
prophylactic measure. Besides, one can never predict with ab- 
solute certainty that a second attack will occur; for only about 
twenty to twenty-five per cent, of all cases of acute appendicitis 
suffer a second attack. As a rule, and unless special reasons (see 
below) render it necessary to perform the interval operation after 
the first attack, I prefer to wait until a second attack has occurred 
and then, by all means, recommend removal of the appendix be- 
fore a third relapse can supervene. This plan also generally ap- 
peals very strongly to the patient, for most people will be very 
apt to imagine that they will constitute one of the lucky seventy- 
five to eighty per cent, of the cases who do not have a relapse and 
they will persist in this belief until the second attack convinces 
them that they belong to the unfortunate minority. 

Under the following circumstances, however^ an interim opera- 
tion is advisable : 

First — When, as stated above, the patient shows a tendency 
to relapses at frequent intervals, immaterial whether the recur- 
rent attacks are light or severe; for the fact that new attacks su- 
pervene despite all care indicates that the local tendency to heal- 
ing and the conditions for a restoration to a normal state are bad 
and that ablation of the diseased parts whose vitality, i. e., re- 
sisting powers are, in most cases, materially reduced, is the only 
effective means of securing permanent relief. 

Second — When the existence of adhesions or of a tumor mass 
in the ileo-cecal region can be determined, which causes pain or 
signs of stenosis of the bowel lumen with constipation (see Sec- 
tion on Intestinal Stenosis). Occasionally, it must be remem- 
bered, adhesions in the appendiceal region cause pain referred to 
other regions of the body, as the gall-bladder, the stomach, the 
urinary bladder, simulating diseases of these organs. In such 
cases, too, surgical treatment of the local conditions in the ileo- 
cecal region frequently brings relief from these symptoms. 

Third — If the diseased region about the appendix constitutes 
a source from which (more or less hypothetical) "reflex" irrita- 
tion emanates^ sufficiently severe to cause functional gastric or 
intestinal disorders and derangements in or about remote organs. 
This event presumably occurs only in neurotic or reduced sub- 



Objections 
against inter- 
val operation 



Indications for 
interim opera- 
tion 

Frequent re- 
currences 



Adhesions 



"Reflex" irrita- 
tion in neu- 
rotic or re- 
duced indi- 
viduals 



644 DISEASES OF THE INTESTINE AND PERITONEUM 

jects; also in psychopathic individuals who have heard much of 
operation for appendicitis and the dangers of the disease if it 
is not operated upon. In such subjects a very pronounced con- 
dition of hypochondriasis is commonly engendered even by mild 
discomfort or pain in the appendiceal region. The mental suf- 
fering is very real and the conditions can often only be relieved 
by an operation. Such individuals, in fact, insist on an opera- 
tion themselves, present themselves to the surgeon rather than to 
the internist with the demand for surgical intervention and are 
quite satisfied, even if the appendix, as is very often the case, is 
found after removal to be in a normal or approximately normal 
condition. 
Summary of A summary of the discussions in regard to the treatment of 

appendicitis from the standpoint of the internist at the last Inter- 
national Medical Congress in Budapest reads as follows, and seems 
to bear out the plea for conservatism made by the author in pre- 
vious editions of this book: — 

Whereas formerly nearly everybody was in favor of an early 
operation in all cases, a more conservative and more expectant 
plan of treatment is now gaining favor. This is due to the fact 
that the dangers of the operation are somewhat underestimated by 
surgeons. When one has seen individuals, who were perfectly 
healthy up to the time of the appendiceal attack, succumb to 
peritonitis, embolism, sub-phrenic abscess, etc. ; when one has 
seen errors in diagnosis, as in acute gastric, cardiac, renal and in- 
testinal disturbances, influenza, croupous pneumonia and typhoid 
fever, lead to the amputation of perfectly normal appendices, one 
becomes more inclined to be conservative. It is well to remember 
that fully 80 per cent, of the cases of appendicitis recover without 
a surgical operation (Ewald). 

In two forms of appendicitis^ however, the internist and the 
surgeon are altogether in accord, first, in a class of cases that are 
seen more frequently in private practice than in the hospital, 
namely, exceedingly mild forms of appendicitis in which surgery 
is hardly contemplated; second, in exceedingly grave cases of sep- 
tic, gangrenous appendicitis in which the patients succumb irre- 
spective of any treatment, surgical or otherwise, that may be in- 
stituted. In appendicitis occurring in children, however, surgery 
is always indicated and the expectant plan is to be condemned, for 
here an apparently harmless disease picture is very apt within a 
very short time to develop into a most dangerous condition. 

A discussion of the technique of surgical intervention and the 
indications for the different possible surgical measures that can 
be employed does not lie within the frame of this volume. 






DISEASES OF THE INTESTINE AND PERITONEUM 645 

CHRONIC PERITONITIS AND TUBERCULOSIS OF 
THE PERITONEUM. 

There are rare cases of chronic (exudative or indurative and Classifications 
adhesive) peritonitis that are not due to tuberculosis, but most 
of the cases encountered are tuberculous in character. In addi- 
tion there is a carcinomatous form of chronic peritonitis that in its 
nature is hopeless and in which treatment is purely symptomatic 
and must be directed against the pain, the ascites, etc. 

In the other varieties of chronic tuberculous and non-tubercu- Spontaneous 
lous peritonitis, spontaneous recovery occasionally takes place. recover y 
Every effort should, therefore, be put forward by the physician internal treat- 
to aid Nature in this endeavor by creating ideal surroundings for ment 
the patient, insisting upon rest, the proper diet and hygiene and 
by symptomatic-ally relieving distressing symptoms as they may 
arise. Surgery, too, occasionally aids in the treatment of chronic Surgery 
peritonitis. Inasmuch as the treatment of the rare, non-tubercu- 
lous variety of chronic peritonitis does not differ materially from 
that of the tuberculous, the latter alone may be discussed. 

A patient suffering from chronic tuberculous peritonitis should Rest and fresh 
remain in bed completely at rest, preferably in the open air or in air 
a thoroughly ventilated room. If it is at all possible the patient 
should be removed to a warm, sunny, equable climate. In the 
treatment of this disease the same rules, broadly speaking, should 
be inaugurated as in the management of any other form of tu- 
berculous infection. These rules, as well as the limitations of 
the fresh air treatment and the contra-indication to its routine 
use have been fully described in the Section on Pulmonary Tu- 
berculosis, and need not be repeated in this place. 

That the diet should be as nutritious and as non-irritating as Diet 
possible is manifest. The selection of the food will have to be 
governed largely by the state of the digestive function and the 
amount of exudate present in the abdomen. Eectal feeding is, 
in many cases, a very useful means of supplying food values that 
cannot safely or with comfort be incorporated by mouth. 

It is somewhat difficult to render conservative judgment in 
regard to the efficacy of various external measures that are em- U res 
ployed in the treatment of tuberculous peritonitis ; for there is 
in this disease a marked tendency to fluctuations in the severity 
of the manifestations and to spontaneous recovery, so that the 
results obtained from various therapeutic measures are never free 
from ambiguity. 

As none of the measures to be presently enumerated can do 
any harm and as a larger proportion of cases seem to recover 



646 



DISEASES OE THE INTESTINE AND PERITONEUM 



Inunction 
with green 
soap 



Mercurial 
ointment 



Bandaging 



Compresses 



Diuretics 



Indications for 
surgical inter- 
vention 



Time of opera- 
tion 



under their use than without them, they should be tried in every 
instance. 

A popular measure, adopted in nearly all large clinics, is 
inunction of the abdominal surfaces with potash soap (sapo kali- 
nus viridis). The soft soap is applied by stirring about a tea- 
spoonful with a little warm water to form a thin paste and rub- 
bing this into the skin of the abdomen. After about half an hour 
the soap is washed off with lukewarm water and the skin care- 
fully dried and powdered. This treatment is repeated every 
evening. As soon as irritation of the skin and eczematous erup- 
tions, etc., appear, the soap is no longer applied to the abdomen, 
but in the same manner to the skin in the lumbar region, the 
back or the buttocks, until the abdominal skin is healed, then it 
is reapplied to the abdomen. This treatment is often followed 
by rapid absorption of the peritoneal exudate. Generally, it is 
true, a thickened omentum or mesentery or massive adhesions 
remain behind. 

Instead of green soap, mercurial ointment may be applied in 
the same way, but it does not seem to be as efficacious in so many 
cases as soap, nor is inuction with this ointment, especially if 
continued for a long time, to be considered an altogether harm- 
less or indifferent procedure. 

In order to promote rest of the abdomen, light bandaging is 
useful. This practice also often affords considerable relief from 
pain; it has no determinable effect on the absorption of the exu- 
date. Priesnitz compresses, hot fomentations or poultices may 
all be applied for producing symptomatic relief, but they cannot 
be credited with influencing the peritoneal process itself in any 
determinable way. 

Diuretics are commonly administered for the purpose of drain- 
ing off fluid from the peritoneal cavity. This practice is a ra- 
tional adjuvant to the treatment, provided too much is not 
expected from increased diuresis. Any of the diuretic drugs 
mentioned in previous sections (see index) may be employed for 
this purpose. 

If rest, proper hygiene and diet combined with inunctions, 
bandaging, the use of compresses and diuretics do not produce 
recovery within a reasonable time; if there is much pain, fever, 
diarrhea and no reduction of the ascites and, above all, if the 
patient continues to fail, to emaciate, then recourse must be had 
to surgery. It is a safe rule not to persist in non-surgical treat- 
ment for longer than two months, provided no improvement be- 
comes manifest during that time. If it should be found that 
the patient rapidly grows worse under internal measures, then 
a laparotomy should be done still sooner. 



Diseases of the intestine and peritoneum 



64? 



The proper operation is incision and drainage of the perito- 
neal cavity. Paracentesis with drainage or aspiration of the as- 
citic fluid, or simple puncture do not yield such favorable re- 
sults. If the primary focus of infection can be discovered (espe- 
cially about the female genitalia, an intestinal ulcer, degenerated 
lymph glands) it should be removed. And if the existence of 
such a focus and its location can be suspected or positively diag- 
nosed in advance, the laparotomy incision should, self-evidently, 
be made in the region of the abdomen where the diseased area 
is located. In cases of tuberculosis peritonitis of obscure origin, 
it is always good practice to explore the female sexual apparatus 
after laparotomy; for the primary focus of the disease will often 
be found about these parts. Cases of tuberculous peritonitis with 
and without exudote are amenable to theatment by laparatomy, 
although the results in the former variety are much better. 

There are no distinct contra-indications to the operation, pro- 
vided it is looked upon as a resort to be adopted only, as stated 
above, when internal measures have been tried in vain; in other 
words, after conditions have been, created and maintained for a 
sufficient length of time that might have favored a spontaneous 
cure, but failed to do so. 

A considerable proportion of the cases will be found, as already 
indicated, to recover under expectant treatment. Of those that 
do not improve a certain number will die with as well as without 
an operation, and a certain proportion will recover after a lap- 
arotomy who would not have recovered without it. 

Unless the patient^ therefore, is in an advanced stage of gen- 
eral tuberculosis or suffers from so serious a type of pulmonarv 
or intestinal tuberculosis that it in itself renders the prognosis 
hopeless, the surgical treatment of chronic tuberculous peritonitis 
should be given a trial in every case of the disease that does not 
vield to medical treatment. 



Incision and 
drainage of the 
peritoneal 
cavity 



Exploration of 
female gen- 
italia 



Contra vindica- 
tions to surgi- 
cal inter- 
vention 



Prognosis un- 
der internal 
and surgical 
treatment 



CHAPTER XII. 

DISEASES OF THE LIVER AND BILE PASSAGES, 



CATARRHAL JAUNDICE. 

The treatment of catarrhal jaundice, especially in the begin- 
ning of the disease, is essentially the same as* the treatment of 
the gastro-intestinal catarrh usually producing the disorder. As the 
treatment of this catarrh has been discussed in full in previous 
sections, it need not be repeated here. 

As a rule the icterus does not develop until several days after 
the onset of the gastro-intestinal disorders (although in excep- 
tional cases it occasionally precedes them), so that, as a rule, 
cleaning out the stomach by lavage or by the use of an emetic is 
superfluous and the chief attention should be given to ridding the 
bowel of any irritating or poisonous material it may still incor- 
porate. For this purpose a brisk purge, best of all, three to five 
grains (0.2 to 0.3 gm.) of calomel, or castor oil,, followed by a 
large dose of sodium phosphate or of magnesium sulphate and a 
colonic flushing, should be given at once upon the appearance of 
icteric symptoms. Such remedies as podophyllin, rhubarb, jalap, 
convolvulin, scammony, gamboge and cathartic acid should not 
be used as purgatives in this condition, because they seem to be 
practically inactive if bile is absent from the bowel. 

As soon as evidence of acute gastro-intestinal dyspepsia is 
present, the patient should either refrain from food altogether 
or should be allowed to take only a little milk, some thin soup or 
strained gruel and water. During this period and until the tongue 
is clear, the fever normal and the epigastric or abdominal discom- 
fort is gone, the patient is best kept in bed. 

With the disappearance or the mitigation of dyspeptic symp- 
toms, the diet should be made more liberal and the patient al- 
lowed to get up a little each day. Some patients, in fact, are able 
without discomfort to attend to their daily work without dis- 
playing any other signs of illness than the yellow discoloration 
of the skin or sclera. Others, again, feel so ill throughout the! 
course of the disease that they are forced to remain in bed for 1 
long periods of time. Thisi occurs particularly in patients who 



Treatment of 
gastro-intesti- 
nal catarrh. 



Purgation by 
castor oil, cal- 
omel, salines, 
colonic flushing 



Purgatives not 
to be employed 



Diet in the 
beginning 



Rest in bed 



Regime after 
disappearance 
of dyspeptic 
symptoms 



650 



DISEASES OF THE LIVER AND BILE PASSAGES 



Exclusion of 
fats 



Albuminous 
foods and car- 
bohydrates 

General char- 
acter of the 
diet 



Predigested 
foods 



Alkaline and 
alkaline-saline 
mineral 
waters 



Abundant 
water drinking 



develop, consecutively to the catarrhal swelling of the bile ducts, 
a condition of hepatic insufficiency (see index) with symptoms of 
profound self-intoxication. 

During the whole period of bile duct occlusion or obstruction 
the diet should be carefully regulated to take into consideration 
the absence of a normal amount of bile from the small intestine. 

Fats should be excluded from the diet, because their emul- 
sification and saponification, hence their absorption, is always 
seriously interfered with, so that they travel through the intes- 
tine in an undigested form, undergo abnormal decomposition 
by intestinal bacteria, with the formation of poisonous and irri- 
tating products and hence increase the catarrhal irritation that 
originally caused the trouble. Inasmuch, moreover, as in many 
cases of catarrhal icterus the pancreatic duct is in all probability 
also stenosed or occluded by catarrhal swelling (as manifested 
by the appearance of abundant undigested meat fibers, fat and 
starchy granules in the stools and sometimes glycosuria) fat is 
especially contra-indicated. 

The chief food, therefore, in catarrhal jaundice should be al- 
buminous material to which may be added easily digestible car- 
bohydrates, preferably dextrinized starchy foods and sugars. All 
food should be administered in an easily digestible form, in the 
beginning, chiefly as liquid and semi-liquid articles, namely broths, 
thin gruels, milk, buttermilk, meat jellies, gelatinous foods, very 
soft boiled or poached eggs; later finely chopped raw or rare beef, 
mutton, poultry, fish,, a little zwieback, toast or crackers soaked in 
milk, gruels made of milk and rice or barle}^, arrowroot, tapioca, 
sago, etc. All foods containing coarse and indigestible particles, 
like skins and tendons, husks, seeds, stems, pips, should be with- 
held for a long time. Alcoholic beverages are to be altogether for- 
bidden. 

In case the pancreatic duct is occluded, too (see above), the 
digestion of albumens also suffers. In such cases the patients 
usually displa}^ a strong aversion for meat, and it should not be 
forced upon them. Here albumoses and peptones, various pre- 
digested vegetable albumens, can be utilized to advantage. 

Alkaline and alkaline-saline waters play an important part in 
the treatment of catarrhal jaundice. Their exact mode of action 
is not quite clear. It has been claimed that the alkalies they con- 
tain are excreted through the bile ducts and exercise a beneficial 
effect on the congested mucous lining of the bile channel. It is 
more probable that they favorably influence the catarrh in the 
small intestine and reduce the swelling around the bile duct orifice 
and hence aid in restoring patency to its lumen. The large 
amount of water that is ingested and absorbed might even be 



BISWASES OE THE LIVER AND BILE PASSAGES 



651 



Intestinal irri- 
gations 



imagined to dilute the bile and hence render its outflow through 
the narrowed bile ducts easier. Whereas this effect of abundant 
water drinking is somewhat problematical, the limitation of water 
drinking certainly leads to thickening of the bile, an event that 
is to be energetically counteracted. Mineral waters at all events 
aid in dissolving some of the mucus accumulated in the bile ducts 
and hence act beneficially. Whatever the exact action of alkaline 
or alkaline-saline mineral waters, or of plain water,, may be, clin- 
ically it may be considered established that the abundant inges- 
tion of such waters, especially when they are taken warm and 
at frequent intervals, materially aids in restoring normal condi- 
tions in catarrhal jaundice. 

Intestinal irrigation with large quantities of water also exer- 
cises a useful effect, so that frequent enemata should be ordered 
in combination with copious water drinking. The injection daily 
by clysma of one or two quarts of cold water is a very popular* 
and a very useful measure. The increased peristalsis of the in- 
testine, combined presumably with increased contractions of the 
gall-duct musculature that is stimulated by such injections, aids 
in the expulsion of mucus and bile from the bile passages; more- 
over, the circulation in the whole portal system, and hence in the 
liver, is accelerated by such injections, while nervous reflex stimuli 
must also be imagined to travel to the liver from the lower bowel. 
All these factors aid in causing a decrease in the swelling of the 
bile-duct lining, in expelling the mucus and in re-establishing the 
flow of bile. 

Finally, the mechanical distention of the colon, which is 
brought about by the injection of large quantities of water, may 
exercise some traction on the region about the bile-duct orifices, 
and hence, too, stimulate concentrations of the latter. 

Whereas all these explanations of the exact action of large, 
cool colonic flushings are more or less hypothetical, clinical ex- 
perience, as in the case of copious water drinking^ shows them to 
be actually useful. 

In order to stimulate the flow of bile towards the intestine Cholagogues 
various cholagogue remedies were formerly employed. As a mat- 
ter of fact, towever, only two drugs can be definitely credited 
with the power to stimulate an increased flow of bile, viz., prep- 
arations of salicylic acid and of bile acids. All the other so- 
called cholagogue remedies act merely as purges and the appear- 
ance of bile in the stools after their administration must be at- 
tributed to the abnormally rapid propulsion of the contents of 
the small intestine into the lower bowel, rather than to any stim- 
ulation of the bile flow. This subject will be referred to again 
in the Section on Cholelithiasis. In catarrhal icterus the use of 






Salicylates 
Bile acids 



652 



DISEASES OF THE LlVER AND BILE PASSAGES 






Bile 



Salol 



Jtching 



Bathing and 
sponging 

Menthol 



cholagogue remedies is not indicated; for the slight increase of 
the pressure within the bile-ducts that may be brought about by 
a stimulation of the flow of bile can hardly be considered effective 
in any way in overcoming the resistance offered to the outflow of 
bile by the catarrhal swelling of the bile-duct mucosa. Moreover, 
as soon as the back pressure within the bile-ducts reaches a cer- 
tain, not very high, point, the manufacture of bile by the hepatic 
cells is automatically inhibited. Before this occurs stimulation 
of the bile flow will probably lead rather to increased diapedesis 
of bile constituents from the bile channels into the blood chan- 
nels, which is detrimental, than to an exit of the bile into the 
bowel through the stenosed bile-ducts. 

Bile and bile acids, however, serve a useful purpose in ca- 
tarrhal jaundice as well as in certain other forms of obstructive 
icterus, because by their administration a certain amount of bile 
is supplied to the small intestine and thereby intestinal digestion 
is aided, while at the same time a mild intestinal antisepsis is 
produced. Salol, too, answers the latter purpose. Both bile and 
bile acid and salicylic acid preparations, however, should be 
given in small doses only. 

Of symptoms complicating catarrhal icterus, intense itching 
often calls for relief. Here a variety of measures must often be 
tried before an efficient remedy is discovered, and it will generally 
be found that the remedies that are helpful at first soon lose 
their power to relieve, so that frequent changes or alternation 
are generally required. Lukewarm baths, cold sponging, alcohol 
rubs, inunction of the skin with cocoa butter or lanolin all oc- 
casionally relieve. One of the best remedies is menthol applied 
in alcoholic solution in the strength of one to five, or in the form 
of a dusting powder in the proportion of one part of menthol 
to five parts of talcum, or as an ointment consisting of menthol, 
one part; sweet oil, two parts; lanolin, twenty-five parts. 



CHRONIC INFLAMMATION OF THE LIVER 



(atrophic, hypertrophic cirrhosis; cardiac, biliary cirr- 
hosis; syphilitic hepatitis; hepatic insufficiency.) 

Hepatic insufficiency is an important symptom complicating a 
great variety of hepatic disorders and leading in its ultimate con- 
sequences to complications about remote organs of the body. Its 
general pathogenetic significance and the means at our disposal 
for correcting hepatic insufficiency may therefore be treated of in 



^Quoted in part from my article on 
Record, 1906. 



Hepatic Insufficiency, Medical 



DISEASES OF THE LIVER AND BILE PASSAGES 



653 



this place, especially as a connected discussion of hepatic insuf- 
ficiency will obviate the necessity of reviewing separately the 
treatment of the . different organic lesions of the liver that pro- 
duce this symptom. 

Whenever an organ fails to perform its functions properly 
we say that it is insufficient. This term may denote both quali- 
tative and quantitative variations from the normal. The more 
complicated and the more active the functions of an organ the 
more liable it is to insufficiency. The liver, therefore, possessing 
as it does the most manifold functions of any organ of the body, 
is particularly subject to functional derangements. Its exposed 
situation, moreover, and the peculiar arrangement of the four 
systems of capillaries that form an intricate labyrinth around 
and through each hepatic cell render the latter especially liable 
to injury by circulating toxins. These poisons reach the liver 
cells continuously from the general circulation in the hepatic 
artery, through the lymphatic circulation (especially from the 
peritoneum), the portal circulation and the bile channels. 

One may differentiate for clinical purposes between mechan- 
ical, parasitic, and toxic causes of hepatic insufficiency, remem- 
bering always that the three may be and usually are, correlated 
and intimately connected. 

Chief among the mechanical causes are all sclerotic changes 
causing overgrowth! or contraction of interstitial liver tissues 
and thereby producing mechanical compression of liver cells or of 
their afferent blood-vessels. Then there is mechanical stenosis, 
occlusion or obliteration of large blood-vessels by embolism, throm- 
bosis, or pressure from without, causing similar nutritional changes 
and, later, necrosis of large areas of liver cells. Again, the bile- 
ducts of the liver may become similarly narrowed or occluded by 
biliary concretions or by the invasion of these channels from with- 
out by parasites, in either instance producing stagnation of bile and 
mechanical compression of liver cells or of the blood-vessels that 
nourish them. Finally, certain heart lesions must be included 
among the mechanical causes, for, by producing stasis of venous 
blood in the capillaries of the liver, they, too, exercise mechanical 
compression upon the hepatic cells and cause derangement of 
their function. 

As has been intimated, the parasitic causes of hepatic insuf- 
ficiency occupy an intermediary position between mechanical and 
toxic causes, for any micro-organism that invades the liver chan- 
nels or the liver tissues proper may act either as a foreign body 
by mechanically destroying liver cells by pressure or by occluding 
the blood-vessels or bile channels, or it may lead to the formation 
of chemical poisons that intoxicate the liver cells, 



Hepatic insuf- 
ficiency 



Causes 



Mechanical 
causes 



Cirrhosis 



Thrombosis 



Bile duct oc- 
clusion (bili- 
ary cirrhosis) 



Heart lesions 
(cardiac cirr- 
hosis) 



Parasitic 
causes 






654 



DISEASES OF THE LIVER AND BILE PASSAGES 



Toxic causes 



Geneial symp- 
tomatology 



The toxins, finally, that can produce hepatic insufficiency 
are so manifold that it would be useless to attempt to enumerate 
them in this place. It! is sufficient to say that all the poisons 
generated in the bowel, the spleen, or the pancreas must travel 
first to the liver before they can reach the general circulation be- 
yond; that all the manifold array of metabolic poisons that can 
be formed in the system at large always comes into particularly 
intimate contact with the liver cells owing to the intricate inter- 
lacing of the capillaries of the hepatic artery and the hepatic 
lymph-channels in the liver. Finally, the liver, possessing as it 
does a most active metabolism of its own, continually manufac- 
tures toxic intermediary bodies within its substance ;* and this is 
particularly the case if its function is in any way deranged. 

The changes that the liver may undergo as a result of all these 
causes may vary from mild transitory functional derangements 
to destructive histological lesions of the hepatic cells. The symp- 
toms of hepatic insufficiency are, therefore, very numerous. This 
is self-evident when we consider the many functions of the liver, 
any one of which may become qualitatively or quantitatively 
perverted. Our knowledge of the finer mechanism of the inter- 
mediary metabolism going on within the liver is, however, still 
so woefully incomplete that it is unfortunately well-nigh im- 
possible to interpret slight derangements of many of these func- 
tions correctly. For this reason we are as yet unable to recog- 
nize as early as we might wish the first manifestations of hepatic 
insufficiency, as we can, for instance, recognize early functional 
changes of the kidneys in the urine, or mild derangements of 
the stomach function in the gastric contents long before ana- 
tomical lesions supervene. From the standpoint of prophylaxis 
and therapy this is particularly deplorable. 

In order to understand the symptomatology of hepatic insuf- 
ficiency and to 1 treat it properly it is necessary to have a clear 
understanding of liver physiology, because it is manifestly im- 
possible to understand the pathology of any group of functions 
unless we understand their physiology; to appreciate or correct 
the abnormal until we understand the normal. 

The normal function of the liver may be summarized under 
the following five heads: (1) formation of urea; (2) conversion 
of sugar into glycogen and the storage of the latter; (3) forma- 
tion of bile; (4) elaboration both by anabolism and catabolism 
of circulating radicals of the fats and albumen; (5) general dis- 
intoxication of circulating poisons and the formation of anti- 
toxic bodies. 

Perversion of these five mentioned functions must lead to the 
following results: 



DISEASES OF THE LIVER AND BILE PASSAGES 



655 



(1) A diminution of the circulating urea and a flooding of 



Decreased urea 
formation 



Interference 
with storage 
of glycogen 



Decreased bile 
formation 



the blood-stream with bodies that have failed to undergo con- 
version into urea in the liver, notably ammonia salts and amido- 
acids, with the appearance of corresponding urinary s} r mptoms — 
i. e., a decrease of the urinary urea and a corresponding increase 
of the urinary ammonia and amido-acids. At the same time, as 
urea is the most potent physiologic diuretic, a decrease in the 
amount of urine. 

(2) Owing to the inability of the liver to convert sugar into 
glycogen and to store the latter, a flooding of the blood-stream 
with an excess of sugar that is derived from the ingested sugar 
or starches, with resulting hyperglycemia and glycosuria. This 
condition may be obscured if the patient does not happen to 
have eaten much starch or sweet foods, but it should readily ap- 
pear even in mild degrees of hepatic insufficiency, as an alimentary 
glycosuria, if the patient is given appreciable quantities of starch 
or sugar in the food. 

(3) The inability of the liver to form bile leads to numerous 
serious consequences that have already been indicated above. Chief 
among these is stasis of bile within the biliary channels and as 
a result diapedesis of poisonous bile constituents from the bile- 
capillaries into the blood-capillaries, in other words, icterus. In 
this connection a very important subject should be mentioned, 
viz., that jaundice occurs only in relatively mild degrees of hep- 
atic insufficiency, whereas in very severe degrees jaundice cannot Cholemia 
possibly occur, for the reason that the liver cells no longer form 

bile. Here the intoxication is especially severe because the prod- 
ucts that should normally he disintoxicated by the liver and 
excreted into the bile pass through the liver cells unchanged and 
are returned to the circulation in a highly toxic form. This con- 
dition has been called by the French grande insufdsance hepatique. 
Another result of failure of the liver cells to produce a normal 
amount and the normal kind of bile is interference with the func- 
tion of the upper portion of the intestinal tract. The withdrawal 
of the bile or the entrance of abnormal bile into the bowel al- 
lows intestinal fermentation to go on unchecked, renders the nor- 
mal emulsification of fats impossible, and produces numerous 
other results that have been enumerated above. At all events 
the withdrawal of normal bile from the bowel in itself causes an 
increased flow of toxic bodies to pour into the liver through the 
portal vein and the intestinal lymphatics and hence promotes the 
causes that produce hepatic insufficiency. The derangement of 
the bile-forming function therefore produces a vicious circle that 
is highly dangerous. 



656 



DISEASES OF THE LIVER AND BILE PASSAGES 



Metabolic de- 
rangements 



Reduced disin- 

toxicating 

power 



Uremia 



General indica- 
tions for 
treatment 

Causal treat- 
ment 



Antiluetic 
treatment in 
syphilitic 
hepatitis 



In the urine this condition usually becomes manifest by an 
increase of the aromatic sulphates, notably indican, and the ap- 
pearance of urobilin, bile pigments, and bile acids. 

(4) Failure of the liver to properly perform its share in the 
metabolism of the albumen and fats causes fragments of the lat- 
ter to be returned to the circulation, either unchanged or disas- 
similated into abnormal products. This, too, produces a general 
intoxication and may, in its ultimate consequences, lead to a 
syndrome that is not distinguishable from uremia, and that is, 
moreover, in all probability uremia. Here the urine contains 
abundant ammonia salts, relatively small quantities of urea and 
usually an abnormal amount of fatty acids, possibly of leucin and 
tyrosin. 

(5) The loss or reduction of the normal disintoxicating power 
of the liver finally is the most serious result of hepatic insuffi- 
ciency and usually constitutes a terminal stage of the affection. 
Here the portals are thrown wide open to the invasion of the 
body with poisons of a thousand kinds that are formed in the 
bowel and in the tissues at large. That the organism cannot 
long withstand this toxic flood is self-evident. In such cases the 
toxicity of the urine will be found to be enormously increased, 
while, at the same time, the kidneys invariably became affected, 
for upon them is now thrown the task of ridding the body of cir- 
culating poisons, a function that normally they share with the 
liver. When renal insufficiency complicates hepatic insufficiency 
a severe toxemia must develop in very short order, and again a 
fulminating syndrone is presented that closely simulates uremia. 

The treatment of hepatic insufficiency may be considered under 
two headings: (1) The suppression of its causes. (2) The 
symptomatic treatment of its manifestations. 

Causal treatment is in most instances synonymous with pro- 
phylaxis. Three factors, as I have mentioned above, chiefly de- 
termine insufficiency of the liver cells, i. e., infection, intoxica- 
tion, mechanical causes. 

The latter, unless we are dealing with some lesion that me- 
chanically compresses the common duct and that can be removed 
surgically, is not amenable to treatment, so that in this instance 
we are limited to symptomatic therapy. There is an exception 
to this rule, that is, syphilis. Here we may be dealing with a 
gumma located in such a way that it produces compression of a 
large bile duct or of an important blood-vessel, or there may be 
a syphilitic interstitial hepatitis. In both of these instances anti- 
syphilitic treatment may remove the cause, mechanical though it 
be. To an extent this also applies to what may be called mechan- 
ical hepatic insufficiency due to venous stasis in the liver follow* 



DISEASES OF THE LIVER AND BILE PASSAGES 



657 



ing heart lesions. Here cardio-tonic treatment may cause the 
symptoms of hepatic insufficiency to disappear. 

In the case of the intoxicating factors the source of poison is 
in the overwhelming majority of cases the gastro-intestinal tract. 
Here causal treatment should be carried out according to the fol- 
lowing principles : To regulate the diet in such a way as to limit 
the ingestion of substances that are in themselves poisonous or that 
undergo changes in the bowel that lead to the formation of pois- 
onous bodies; to reduce to the lowest possible minimum intestinal 
putrefaction; to prevent as far as possible the absorption of what- 
ever poisonous bodies may have gained entrance to the bowel or 
may have been formed there; to promote the destruction of the 
latter in case they enter the circulation, and above all, to hasten 
the rapid elimination of circulating toxins. The latter indication 
prevails with equal force in the case of poisons that are not formed 
within the bowel, but that are generated within the tissues of 
the bod; (endogenous poisons), as in infectious diseases and in a 
variety of metabolic disorders. 

Under the head of causal treatment all those measures might 
also be included that we know are capable of stimulating the 
hepatic cells to renewed activity when their energies begin to flag, 
but this treatment must be carried out with conservatism, as I 
will have occasion to show further on. 

Symptomatic treatment includes the treatment of the protean 
array of sequelae of hepatic insufficiency. As derangement of the 
liver function in its ultimate consequences may lead to the great- 
est variety of psychic, nervous, cardio-vascular, renal and meta- 
bolic disorders, symptomatic treatment of hepatic insufficiency, as 
stated above, in the broader sense covers a large field of therapy. 

Probably the most important dietetic rule in the treatment 
of hepatic insufficiency is a negative one, i. e., that all alcoholic 
beverages should be rigidly excluded from the diet. We do not 
realize sufficiently that pure alcohol is the least toxic of the alco- 
hols that are used in the food of man ; the higher alcohols and cer- 
tain aldehydes and essential oils that are found in cheap liquors 
and that bestow the aroma or bouquet upon the various wines, 
liqueurs, and cordials, are much more poisonous even in the small 
quantities in which they are used; thus, e. g., absinthe contains 
some eleven different principles, all of which are poisonous. Al- 
cohol itself, therefore, unless taken in enormous quantities, is 
not so terribly dangerous; but no one drinks pure dilute alcohol, 
but rather alcoholic beverages of various kinds, and as the latter 
are poisonous on account of the impurities they contain, it should 
be a cardinal rule in the treatment of hepatic insufficiency to ex- 
clude them rigidly from the diet. 



Intestinal anti- 
sepsis 



Stimulation of 
hepatic cells 



Symptomatic 
treatment 



Dietetic treat- 
ment 



658 



DISEASES OF THE LIVER AND BILE PASSAGES 



Spices and 
condiments 



Reduction 
fats 



Meat and eggs 



Carbohydrates 
Vegetables 



On the same grounds spices and condiments should always 
be excluded because they contain essences and alkaloids that are 
toxic to the liver. 
of A second cardinal rule is to limit the ingestion of fats, for 

they are very poorly digested owing to the deficiency of bile acids 
from the bowel ; it is clear that in this case, as stated above, they 
are not properly saponified and emulsified, undergo rapid decom- 
position in the bowel, and in this way lead to the formation of 
acid and acrid products that are highly irritating to the liver 
and the bowel. It has been shown that in cases of hepatic in- 
sufficiency the urinary toxicity increases greatly when much fat 
is given. While it is not necessary, therefore, to exclude the fats 
altogether from the diet, they should be reduced to a minimum. 

Meat and eggs should also be reduced, for they furnish the 
bulk of the most toxic intestinal products whenever intestinal 
putrefaction goes on unchecked, and this we know to be the case 
when the bile is deficient or its composition is changed. 

There remain, therefore, as chief articles of food, vegetables 
and carbohydrates ; the latter, in particular, are not toxic nor do 
they lead to the formation of toxic bodies in the bowel; and be- 
sides, sugar, as we know, stimulates the liver functions to ac- 
tivity. Of course, care should always be exercised not to admin- 
ister a diet containing too large a proportion of carbohydrate 
food, for otherwise fermentative dyspepsia, constipation, and a 
variety of digestive disorders may supervene. One should simply 
increase the amount of carbohydrate food to replace the deficit of 
fat. Milk can always be given with impunity. An exclusive 
milk diet, however, is for many reasons objectionable. (See 
index). 

To summarize, the patient should be placed upon a bland 
mixed diet, containing no alcoholic beverages^ a minimum of fat, 
a small amount of albuminous food, and plenty of fresh fruits, 
vegetables, milk, cereals, starches, and, with care, sweets. That 
the details of this diet should be regulated in such a way as to con- 
sider the individual idiosyncrasies and tastes, and above all com- 
plications in other organs, notably the kidneys, need hardly be 
emphasized. 

In view of the fact that the chief source of the poisons that 
intoxicate the liver and produce hepatic insufficiency is the in- 
testinal tract, it is of paramount importance to attempt intestinal 
antisepsis (see index) in every case of hepatic insufficiency that 
comes under observation. 
Evacuants That the absorption of bowel poisons after they have once 

formed can be restricted by the use of evacuants is clear. A sa- 
line laxative given at frequent intervals, combined possibly with 



Milk 



General ar- 
rangement of 
the diet 






DISEASES OF THE LIVER AND BILE PASSAGES 



659 



enemas to clean out the lower bowel, is a useful measure. Purga- 
tives or drastics that can irritate the liver should be used cau- 
tiously. 

All attempts that have so far been made to promote the de- 
struction of poisons after they have once been absorbed have been 
abortive. A. Bobin, as is well known, introduced a so-called 
oxidizing treatment and advised the inhalation of oxygen, the 
use of iron and manganese preparations. I have never seen any 
tangible good results follow this treatment. Cold hydro thera- 
peutic measures, thanks to the leucocytosis, the increased meta- 
bolism, and the better circulation of lymph they produce, are of 
much use. 

The elimination of absorbed poisons by the various emuncto- 
ries of the body is always indicated. Here elimination by ca- 
tharsis (see above) and diaphoresis, preferably brought about 
by hydriatic measures, has a useful place. To attempt elimina- 
tion by forced diuresis is, however, dangerous, as the toxins that 
are forced through the kidneys are bound to irritate them, and 
injury to the kidneys should of all things be avoided. 

The last and most important task is to attempt to restore 
the function of the destroyed hepatic cells. Here the same prin- 
ciples must obtain as in the treatment of any organ that has be- 
come fatigued. In very mild cases slight stimulation may at 
once restore normal tone ; in more chronic conditions, however, 
rest is the prime requisite, for when the affected organ is spared 
nature soon re-establishes functional equilibrium. We follow this 
plan exclusively in diseases of the stomach by withdrawing food 
for a while or by reducing the daily ration. We do it in dis- 
eases of the nervous system when we give a rest cure. We do 
it in diseases of the heart when we put the patient on a mild, non- 
irritating diet with an ice bag over the heart. We are beginning 
to apply the same plan in diseases of the kidneys, and it cer- 
tainly has a grateful field of application in the case of the liver. 

Following a period of rest, what might be termed gentle ex- 
ercise of the organ may be instituted either by throwing upon 
the liver tasks that it should normally be able to fulfill, or by 
gently stimulating it with remedies or physical measures that 
we know can produce this purpose. Active stimulation with pow- 
erful remedies should be reserved as an emergency measure in 
extreme cases, for nothing will so rapidly produce complete func- 
tional inadequacy of an organ that is functionally impaired as 
over-stimulation in the beginning. 

For the purpose of stimulating the function of the liver we 
can have recourse in the first place to certain hydrotherapeutic 
measures. It has been established by careful studies that general 



Oxidizing 
treatment 



Cold hydro- 
therapy 



Diaphoresis 
and catharsis 



To restore 
function of 
hepatic cells 



Rest 



Exercise 



Danger of ac- 
tive stimula- 
tion of the 
liver 



Hydrotherapy 



660 



DISEASES OF THE LIVER AND BILE PASSAGES 



Cholagogues 



Alkalies 
Antipyrin 



Urea 



Organotherapy 
Liver extracts 



Dangers of op- 
erative inter- 
ference and 
chloroform 



hot baths or the brief application of cold locally over the liver, 
preferably in the form of a stream of cold water directed for a 
minute or two against the hepatic region, will energetically stim- 
ulate the flow of bile. The same result can be obtained by the 
application of a so-called Priesnitz compress over the liver region. 
A towel is wrung out of cold water and laid over the liver and 
covered with a flannel. 

Many remedies are said to stimulate the formation of bile. 
Unfortunately, most so-called cholagogues do not possess this 
power at all, but simply irritate the stomach, the intestine, and 
the liver. Best of all are the salicylic preparations and the bile 
acids (see supra). Preference should be given to the latter rem- 
edy because the salicylates are somewhat irritating to the kid- 
neys. The stimulation of the glycogenic function of the liver 
can be brought about by an active alkali therapy. Antipyrin 3 too, 
possesses this power. Best of all, however, are the starchy and 
sweet foods, and these are already properly included in the diet. 

We know of no remedy that can stimulate the urea-forming 
function of the liver. The administration of abundant albumin- 
ous food constitutes a physiological stimulant to this function, 
and, if sufficient care is exercised that the bowel is kept aseptic, 
there is no reason why enough of albumen should not be given 
for this purpose, only ? however, in mild stages of the disease. 
Some writers have advised the use of urea, itself, claiming that 
a certain amount of urea is necessary, especially in order to pro- 
mote diuresis, and that where its formation is deficient it should 
be supplied. This plan does not appeal to me, and, despite the 
various favorable reports on this therapy I have never been able 
to convince myself of its value. 

Liver extracts given in the form of powdered calf's liver or 
pork liver, suspended in milk or water, by enemata, or even sub- 
cutaneously, is worthy of trial. Symptomatically I have seen some 
good results from the ingestion of liver extract in cases of cirrho- 
sis of the liver with hepatic insufficienc}^ especially in the direc- 
tion of an increased urea excretion, an increased tolerance for 
carbohydrates, and an apparent improvement in some of the 
nervous manifestations. That the administration of liver extract 
stimulates the regeneration of liver cells, as is claimed by some 
clinicians (Gilbert and Carnot) ; that is produces a vicarious 
hypertrophy of those portions of the liver that are not affected is 
hard to prove. 

Finally, something may be said in regard to the danger of 
operative interference in cases of hepatic insufficiency. There is 
in most of these cases a tendency to hemorrhage due, possibly, to 
the circulation in excess of bile acids ; for the latter have a dis- 



DISEASES OP THE LIVER AND BILE PASSAGES 



661 



tion 



tinct hemolytic power and interfere with the coagulability of the 
blood. Besides, the administration of chloroform is a very dan- 
gerous procedure in any case, even of mild hepatic insufficiency, 
for, in predisposed subjects who, we must assume, possess an 
idiosyncrasy against chloroform, a condition may develop which 
closely simulates acute yellow atrophy of the liver, both clinically 
and anatomically. I think it is just as important for this reason 
that surgeons should, as far as possible, examine the functional 
state of the liver before an operation as they do, or should, study 
the condition of the kidneys. If any of the evidences of hepatic 
insufficiency that have been enumerated above should be present, 
then chloroform at all events should not be administered as an 
anesthetic, and the possibility of profuse capillary hemorrhages 
be remembered. If it were not for this difficulty of operating 
upon cases of hepatic insufficiency the so-called Talma operation, Talma opera. 
which consists, in producing an artificial collateral path for the 
flow of blood from the portal circulation into the systemic circu- 
lation, either by epipoplexy or by curetting the parietal peritoneum 
and the omentum, would be more useful than it really is. The 
Talma operation is indicated under the following conditions: 
First, in stenosis of the portal vein; second, in disorders involving 
the distribution of the portal vein in the liver. To the latter 
category belong, first, hepatic cirrhosis, both the atrophic as well 
as the hypertrophic form with icterus; second, cardiac cirrhosis; 
third, pericardiac pseudo-cirrhosis; fourth, Band's disease in the 
third stage. 

Treatment of the dyspeptic symptoms, the ascites, the hem- 
orrhages, the cardio-vascular changes, the nervous manifestations, 
the nephritic lesions, and the icterus that accompany or follow 
chronic inflammations of the liver need not be discussed again 
in this place, the different measures to be employed having been 
fully presented in appropriate sections. 



Symptomatic 
treatment 



CHOLELITHIASIS. 



In simple uncomplicated cholelithiasis, i. e., in a subject show- Prophylactic 
ing a tendency to recurrent attacks of gall stone colic, prophylac- r a men 
tic treatment directed towards promoting an active flow of bile, 
and towards hindering catarrhal inflammation of the gall-ducts 
and the gall-bladder, can be instituted. 

Every endeavor should be put forward to promote a steady Stimulation of 
flow of bile towards the intestine; for, in this way stasis of bile the bile ^ ow 
constituents is prevented. This is an important element in prophy- 



662 



DISEASES OF THE LIVER AND BILE PASSAGES 



Diet 

Albumens 

Carbohydrates 
Fats 



Alcohol 



Small meals at 
frequent inter- 
vals 



Abundant 
water drinking 



Mineral waters 



laxis, inasmuch as stagnating bile forms a suitable nidus for the 
development of bacteria. Besides, the invasion of the bile ducts 
and gall-bladder by bacteria from the intestine is rendered quite 
difficult if the bowel passages are constantly drained by an active 
stream of bile flowing towards the intestine. 

In order to stimulate the current of bile the diet should be 
mixed. It should contain an abundant quantity of albumen and 
relatively small quantities of carbohydrates and fats. Albumens 
more than starchy, sweet and fat foods lead to the formation 
of abundant bile acids and the latter render the bile more fluid, 
more abundant and also impart to it certain antiseptic proper- 
ties. Carbohydrate foods, on account of their tendency to pro- 
duce congestion of the liver and intestinal fermentation, when 
given in abundant quantities, should be somewhat reduced in 
quantity. Fats are apt to irritate the bowel and to produce in- 
testinal dyspepsia, hence they should be very much reduced or 
altogether excluded from the diet, especially as their presence in 
the bowel would be particularly detrimental should an attack 
of gall stone colic with gall-duct occlusion suddenly supervene. 
Alcoholic beverages, spices, condiments and all irritating or coarse 
foods that can determine catarrhal conditions of the upper di- 
gestive tract should be avoided. 

A steady flow of bile, moreover, is stimulated by the admin- 
istration of meals at frequent intervals. Consequently in addi- 
tion to the three regular main meals a day a patient with cholelith- 
iasis should be instructed to take a glass of milk or an egg-nog 
with a few crackers, or a piece of toast, in the middle of the fore- 
noon and the middle of the afternoon. The administration of 
a similar meal in the middle of the night is rarely necessary. 

Plenty of water, especially some of the alkaline or alkaline- 
saline mineral waters, should be taken; the latter in particular 
aid in dissolving the mucus in the bile passages and hence in 
maintaining the bile ducts open. It is questionable whether al- 
kaline waters exercise any determinable effect upon the alkalinity 
of the bile and hence, as some clinicians claim, aid in keeping the 
ingredients that precipitate in the form of concretions in so- 
lution. So much is certain, that they exercise no solvent action 
upon gall stones after the latter have once formed. The chola- 
gogue action of mineral waters is also in doubt and the dilution 
of the bile that is postulated from the administration of abundant 
liquids is problematical. Too great restriction of the intake, how- 
ever, assuredly leads to greater viscidity of the bile, hence favors 
sluggishness of the bile stream and stagnation. The chief action 
of alkaline mineral waters is presumably exercised in preventing 
gastro-intestinal catarrh, hence abnormal fermentation, the devel- 



DISEASES OE THE LIVER AND BILE PASSAGES 



663 



Resort treat- 
ment 



Exercise and 

massage 



opment of bacteria and catarrhal swelling about the orifices of 
the gall-ducts. The laxative properties-, finally, of certain min- 
eral waters stimulate intestinal peristalsis and indirectly also 
peristalsis in the bile ducts; in this way, then, they also aid in 
the expulsion of the bile. 

The great benefits 1 accruing from the use of certain mineral 
waters taken in resorts must, be attributed only in part to the 
abundant ingestion of the liquid and the incorporation of the 
alkaline and saline principles they contain. The life in a resort, 
itself, the respite from the daily routine, the out-door existence, 
the careful regulation of the general regime and of the exercise, 
the scientific employment of hydrotherapeutic measures and the 
management of the case by skilled specialists are all elements 
that contribute towards the good results obtained from the resort 
treatment of cholelithiasis. 

The regulation of exercise and abdominal massage are all use- 
ful adjuvants to the treatment, chiefly on account of their power 
to stimulate the flow of bile. Violent exercise should never be 
permitted to patients showing a tendency to gall stone colic ; for 
sudden movements of the body are very apt to cause impaction 
of a gall stone and to precipitate an attack of colic. Violent ex- 
ercise is altogether contra-indicated in cases of cholelithiasis com- 
plicated with cholecystitis and cholangitis, or in patients with 
chronic icterus due to impaction of a gall stone; for in these cases 
there is always danger of perforation and resulting peritonitis. 

The clothing should be loose and all pressure by the cloth- 
ing on the liver region avoided. In women tight skirt bands and 
corsets should be forbidden and the clothing suspended from the 
shoulders. In men the wearing of belts is to be forbidden. It is 
usually a good plan to order these patients to loosen the clothing 
about the waist after meals. 

The use of cholagogues is indicated as a prophylactic measure Cholagogues 
in cases of cholelithiasis. As stated above in the Section on Ca- 
tarrhal Jaundice, only two remedies can directly be credited with 
bile-stimulating properties, namely, the bile acids and the salicy- 
lates. In addition to their cholagogue powers, these two remedies 
also possess antiseptic properties that are especially useful in 
cholelithiasis; for both these remedies after absorption from the 
bowel are re-excreted in part via the gall-ducts, hence they pro- 
mote an increased outpouring of bile that has been rendered, to 
some degree at least, antiseptic. 

The best way to administer bile acids is in the form of sodium 
glycocholate in doses of one-half to two grains (0.03 to 0.13 gm.) 
Salicylic acid is better than the salicylates and a pill containing a 
grain each of sodium glycocholate and of salicylic acid, given three Salicylic acid 



Clothing 



Sodium glyco- 
cholate 



664 



DISEASES OE THE LIVER AND BILE PASSAGES 



Expulsion of 
gall stones 



Olive oil 



Enteroliths 
after oil 



Glycerin 



or four times a day, must be considered an efficient means to stim- 
ulate the flow of bile. All the other remedies that have been 
recommended at different times as cholagogues act presumably 
chiefly as laxatives. They may exercise some effect upon the flow 
of bile by increasing intestinal peristalsis and indirectly the peris- 
talsis of the gall-ducts. They are vastly inferior, however, in 
efficacy to the two above-mentioned remedies (see also Section 
on Catarrhal Jaundice). 

All the measures enumerated not only aid in preventing the 
formation of gall stones, but also assist in the expulsion of gall 
stones that may be present in the bile ducts. In addition certain 
other remedies may be used for the latter purpose, namely, olive 
oil and glycerin. 

The former is warmly recommended by some clinicians and 
condemned as utterly useless by others. Personally, I have never 
been convinced that the use of olive oil materially influences the 
course of a case of cholelithiasis, prevents the formation of gall 
stones, or aids in their expulsion. It is very questionable, in fact, 
whether the oil after absorption really enters the bile ducts and is 
re-excreted with the bile. Whatever good effects may occasionally 
be observed from the use of olive oil must be attributed in great 
part, at least, to its slightly nauseating and laxative properties 
whereby it stimulates peristalsis and contraction of the bile ducts. 
After the administration of olive oil small masses of saponified 
oleic acid are frequently deposited with the feces, and it is quite 
probable that these enteroliths have occasionally been taken for 
expelled gall stones. 

Olive oil may either be given in one or two tablespoonful doses 
in the evening before retiring, or, better still, in fifteen drop doses 
before breakfast on an empty stomach, every day or every other 
day. A convenient formula for the administration of olive oil 
is the following, recommended by Rosenberg : 



u 



Olive oil 
Brandy 

Menthol 

Yolk of one egg 



200.0 

20.0 

0.2 



This mass is thoroughly mixed and taken in two doses an 
hour apart. The disagreeable fatty taste of the oil can be removed 
by eating little pieces of orange or lemon peel, or taking a tea- 
spoonful of orange or lemon syrup. 

Glycerin, which is sometimes a very effective remedy in renal 
lithiasis, is not so useful in cholelithiasis. It should be given in 
the dose of about half a teaspoonful in some mineral water once 



DISEASES OF THE LIVER AND BILE PASSAGES 



665 



a day. Glycerin, too, probably acts on account of its laxative 
properties. 

The attempt to promote solution of gall stones in the biliary 
passages by the administration of any medicine by mouth must 
be considered altogether futile. Various drugs, like olive oil, 
ether, turpentine, chloroform, sodium oleate (eunatrol), and many 
others that are credited with this power are, I think, altogether 
inert in this direction. Oleic acid must, however, be considered 
a useful prophylactic against the formation of concretions in the 
gall-bladder. It is especially indicated after an operation for the 
removal of gall-stones as a prophylactic against recurrence. It 
should be given in capsules in the dose of 0.5 eg. If the oleic acid 
is perfectly fresh and chemically pure, it will not irritate the 
stomach, and given in this way it is superior to the oleate of so- 
dium that almost invariably produces some gastric irritation with 
eructations of gas. The pure acid should be perfectly trans- 
parent and possess a light straw-yellow color. 

If large masses of gall stones are present and if their removal 
becomes desirable (see below), then surgical means should be 
promptly adopted and no time wasted with medicinal measures. 

In view of the tendency nowadays to operate somewhat pro- 
miscuously in every case of gall stone disease, a certain warning 
may be uttered. There are distinct indications for surgical inter- 
vention which will be presently discussed. The appearance of gall 
stone symptoms, or even of signs of gall-bladder or bile channel 
infection, must not, however, be considered the signal for an op- 
eration in every case. A large proportion of patients suffering 
from chronic cholelithiasis recover without surgery, and it is well 
worth while in each case to give the patients the full benefit of 
medical treatment. 

Surgery at best can only remove gall stones or promote drain- 
age of the gall ducts or gall bladder, but it cannot affect the mor- 
bid processes that originally led to the formation of gall stones 
or infection of the bile passages. The treatment of the case, more- 
over, is by no means completed after the gall stones have been 
removed, or the gall-bladder or the gall passages have been drained ; 
and a patient once afflicted with gall stones, even after he has 
been operated upon, should remain under careful supervision until 
the hepatic disorder and the catarrhal conditions of the bile pas- 
sages are completely cured. This aim can only be accomplished 
by medical means, namely, by careful regulation of the patient's 
diet and general mode of life, by the administration of proper 
remedies and the institution of the other measures that have just 
been enumerated. 



The solution of 
gall stones 



Surgical re- 
moval of gall 
stones 



Warning 
against pro- 
miscuous sur- 
gical treatment 
in gall stone 
disease 



Limitations of 
surgery 



666 



DISEASES OF THE LIVER AND BILE PASSAGES 



Indications 
surgical in- 
tervention 



for 



Recurrent at- 
tacks of colic 
Suppurative 
cholangitis and 
cholecystitis 



Complete gall 
duct occlusion 



Peritonitic 
signs 



Adhesions 



Under the following conditions surgical intervention, how- 
ever, becomes necessary and constitutes the only effective means 
of treating these cases, namely: 

First. In frequently recurring attacks of gall stone colic that 
do not yield to internal treatment, that reduce the patient's health 
and impair his working capacity, especially if the presence of 
many gall stones in the gall bladder can be determined. 

While one can never predict that an attack of gall stone colic 
may not be the last one, it is, nevertheless, important to remem- 
ber that each attack injures the bile passage and may lead to ul- 
ceration or the formation of dangerous strictures or adhesions 
or stenosis (or acute, hemorrhagic pancreatitis). Kepeated at- 
tacks, therefore, in which any evidence of such complications ap- 
pears, must be considered fit for surgical intervention. 

Second. If suppurative cholangitis or cholecystitis compli- 
cates the disease. Here spontaneous recovery may occur (see be- 
low), but free drainage and irrigation and removal of the gall 
stones that keep up the irritation of the gall-bladder and bile 
passages, is usually the quickest and most certain means of pro- 
ducing a cure. 

Third. In complete common duct occlusion which persists 
and leads to the development of profound icterus. This condition 
should never be allowed to persist for longer than two months at 
most. If, during this time, serious impairment of the patient's 
health occurs, an operation should be performed much sooner. 
It is usually dangerous to wait too long in this condition, because 
in chronic icterus of this kind a tendency to hemorrhage develops 
which may render an operation especially dangerous. 

Fourth. Peritonitic symptoms developing as the result of per- 
foration or rupture of the gall-bladder or its ducts, occurring either 
during an attack of gall stone colic or developing slowly in the 
course of chronic stenosis or ulceration of the gall-bladder or the 
bile duct. 

Fifth. Adhesions forming around the gall-bladder and pro- 
ducing mechanical dislocation or stenosis of adjacent organs, es- 
pecially the stomach, the duodenum and the colon, and causing a 
variety of distressing symptoms, chiefly pain, gastro-iutestinal 
disorders, and biliary colic. While it is true that adhesions are apt 
to form again even after an operation, a skillful operator can 
usually manage the field of operation in such a way that the new 
adhesions form in a more favorable locality. 



Treatment of 
the acute at- 
tack 



TREATMENT OF THE ACUTE ATTACK. 

In treating an acute attack of gall stone colic the following 
indications must be met: 



DISEASES OF THE LIVER AND BILE PASSAGES 



661 



First, to stop the excruciating pain. 

Second, to facilitate the passage of the stone and prevent its 
permanent impaction. 

Both of these indications are best met by opiates; for the 
latter not only promptly stop the pain, but also cause the relaxa- 
tion of the muscularis lining the gall-ducts and hence facilitate 
the passage of the stone. One must imagine that spastic reflex 
contractions of certain portions of the bile duct are stimulated 
by the stone and that, in this way, the concretion is held tightly 
in one place. If opium cr morphine are given, this tonic con- 
traction stops and new peristaltic movements are gradually re- 
sumed until the stone is either expelled or is again arrested by 
spastic contractions of some part of the bile passages farther 
down; as soon as this occurs an opiate should again be admin- 
istered. 

The best way to administer opiates is, therefore, to give a hypo- 
dermic injection of a quarter of a grain (0.005 gm.) of mor- 
phine as soon as the patient is seen and to repeat the dose once 
or twice according to the requirements of the case; or a hypo- 
dermic of morphine may be given at first and later, when at- 
tacks of colic return, ten to twenty drops of the tincture of 
opium by mouth, to be repeated at intervals of one or two hours. 

Belladonna and atropine also relieve the muscle spasm and 
can be used instead of, or together with, opium or morphine. 
Belladonna is best given either as the extract of the leaves in 
powder form in the dose of 14 to V2 grain (0.015 to 0.03 gm.) ; 
or in the dose of five to fifteen minims (0.3 to 1 cc.) of the tinc- 
ture of belladonna leaves repeated several times; or as atropine 
sulphate, in the dose of one-hundredth to one two-hundredth of a 
grain (y 2 to 1 mg.), either alone or in combination with a quar- 
ter of a grain (0.015 gm.) of morphine. 

Other remedies employed for the purpose of stopping the pain 
in cholelithiasis are antipyrin and other members of the group of 
coal tar analgesics, sodium salicylate and many more. No rem- 
edy, however, is as efficacious as opium or belladonna. If the 
pain is very severe and does not yield promptly to the adminis- 
tration of morphine, then a few drops of choloroform on ice, or a 
teaspoonful of chloroform water, repeated at frequent intervals, 
or even a few whiffs of chloroform, may have to be given. Chloral 
is not as valuable as chloroform and is, in most cases, a dangerous 
remedy to be employed. 

Heat or cold may be applied locally. Heat is usually much 
more effective in alleviating the pain, especially when applied con- 
tinuously by means of hot poultices, a Leiter coil charged with 
hot water or a thermophore (see index). Immersion of the pa- 



Opiates 



Dose and ad- 
ministration 



Belladonna and 
atropine 



Antipyrin and 
other anal- 
gesics 

Sodium sal- 
icylate 



Chloroform 



Chloral 



Hot and cold 
applications 



Hot bath 



668 



DISEASES OF THE LIVER AND BILE PASSAGES 



Cold applica- 
tions 



Laxatives 
Enemata 



Collapse 
Analeptics 



Alcoholic 
drinks 



tient in a hot bath is also a very effective means, in most cases, 
of cutting the attack short. 

If heat is not well borne, and this is most apt to be the case, 
especially in the presence of complicating cholecystitis and cho- 
langitis, cold may be nsed instead. As pressure upon the gall- 
bladder region is rarely well tolerated, it is best to suspend the ice 
bag over the patient and to have it barely in contact with the gall- 
bladder region, or to use a Leiter coil charged with ice cold water 
applied to the same place. 

Free evacuation of the bowels by the use of laxatives and 
enemata should always be promoted when an attack of gall stone 
colic occurs. If castor oil or sodium phosphate are vomited, then 
high rectal injections of cold water may be administered both for 
the purpose of cleaning out the lower bowel and for the purpose 
of stimulating intestinal peristalsis (see the Section on Catarrhal 
Icterus). Enemata of olive oil are also useful. 

If very reduced and weak patients should develop symptoms 
of collapse or shock from the severe pain, analeptics (see page 
index) may have to be administered, especially if the pain is not 
promptly controlled by the use of morphine. A little champagne, 
hot alcoholic drinks, camphor, ether, ammonia, or adrenalin chlo- 
ride administered by mouth or hypodermicallv are all of use. 



CHOLANGITIS AND CHOLECYSTITIS. 



Cholangitis 
and cholecys- 
titis 



Cholagogue- 

antiseptic 

treatment 



In infections of the bile ducts and gall-bladder (cholangitis 
and cholecystitis), an attempt should always be made to control 
the infection by medical means; for this purpose hot or cold ap- 
plications to the gall-bladder region should be made and con- 
tinued for several days. The choice of heat or cold will have to 
be made according to the subjective sensations of the patients. 

The bowels should be thoroughly cleaned out and kept clean 
by the administration of laxatives and enemata. Here a chola- 
gogue-antiseptic treatment with the salicylic acid and bile acid 
combination described above, to which may be added half a grain 
of menthol as an antiseptic and anesthetic, is useful. The fol- 
lowing combination is also very popular for continued use: 

Sodium benzoate, 0.5 

Sodium salicylate, 1.0 

In pill or capsule, to be given three or four 
times a day. (Chauffard.) 

I consider the salicylic acid and bile acid pill, however, to be 
more efficacious. 



DISEASES OF THE LIVER AND BILE PASSAGES 669 

The diet during this treatment should be bland and non- Diet 
irritating. During the first week of the bile passage infection, 
milk alone is best given, during the second week soups or thin 
gruels may be added to the milk, and during the third week and 
later a little meat and a gradual resumption of a general mixed 
diet may be allowed. 

If all these measures fail within a few months to relieve the Surgical 
inflammation, or sooner if the patient suffers from recurrent at- treatment 
tacks of pain with or without icterus, and develops signs of gen- 
eral septic toxemia, loses much strength, becomes emaciated and 
anemic, recourse must be had to surgery. Opening of the gall- 
bladder, free drainage and irrigation usually produce prompt re- 
lief and, in most cases, constitute the only means of effecting a 
permanent cure of this obstinate and dangerous condition. 



CHAPTER XIII. 

THE COMMONER INTOXICATIONS. 

In so far as the management of poisoning cases usually par- 
takes of the character of emergency treatment, I have decided to 
write this chapter in the form of a summary of the measures to be 
adopted, tabulated alphabetically, for ready reference. 

The first step to be taken in every case of poisoning is to remove Emergency 
as much of the poison as possible from the point of entry. If the 
poison has been swallowed, gastric lavage with moderate quantities Gastric lavage 
of plain water is always the first step. Large quantities of fluid 
should, however, never be used for lavage on account of the danger 
of rupturing or perforating the stomach wall, in case the poison, 
owing to its corrosive action, should have produced erosion of the 
stomach lining. In non-corrosive poisoning this precaution need 
not be taken. That under special conditions, presently to be men- 
tioned, specific medication of the wash waters is useful need hardly 
be emphasized. In addition an emetic should always promptly be 
administered. The best of all is a subcutaneous injection of apo- 
morphine in the dose of 0.01 g. In children and in very much 
reduced individuals half of this quantity. Besides, mechanical irri- 
tation of the palate and the administration of luke warm water. 
To clean out the bowel a brisk laxative should be given and lavage 
of the colon practised. 

If there is reason to suspect that the poison has entered the Venesection 
blood, or if the poison has directly entered the circulation, then 
venesection followed by an infusion of an alkaline-saline solution 
(1 liter of a 0.9 per cent, sodium chloride solution plus 1 g. sodium 
bicarbonate) should be performed. The introduction of a saline 
solution of this kind also favors the elimination of the poison 
through the kidneys and should be practised, in case it is impos- 
sible to give abundant fluid or diuretics by mouth. If the poison 
has entered through a wound, the latter should be thoroughly 
cleansed with abundant sterile water or with a solution of the 
chemical antidote; as much of the poison as possible should be 
removed by suction or, if necessary, by cauterization of the wound 
surface. 



672 



THE COMMONER INTOXICATIONS 



General anti- 
dotes 



Symptomatic 
measures 



In case it can be determined that the poison is an acid, an alkali, 
or an alkaloid, then the following general antidotes should be em- 
ployed in each class, viz. : 

In poisoning with acids, antacids by mouth, powdered chalk, 
white of egg, milk, powdered egg shells. Externally soda bicar- 
bonate solution, or soap containing free alkali, like green soap. 

In poisoning with alkalies (lye), some acid substance. The 
most accessible being as a rule dilute vinegar, lemon juice or tar- 
taric acid, the latter being used in the strength of 1/3 of a tea- 
spoonful to a liter of water. 

In poisoning with an alkaloid, tannin or tannic acid in dilute 
watery solution (1 to 30) powdered charcoal suspended in water, 
or a solution of iodin and potassium iodide (LugoPs solution, page 
673). 

Symptomatically the following measures should be employed: 

For excessive vomiting, small pills of ice. 

For excruciating pain in the abdomen opium or morphine hypo- 
dermically. 

For great reduction of the body temperature (especially after 
poisoning with narcotic drugs) hot blankets,, hot water bottles, hot 
baths, a thorough rubbing and manipulation of the extremities. 

For erosion of the mouth, pharynx or esophagus mucilaginous 
substances, as ordinary mucilage decoction or tragacanth dissolved 
in water. 

For suspension of breathing immersion in a hot bath and pour- 
ing of cold water over the nape of the neck, the chest and the back. 
The patient should be laid down flat with the head lowered, artifi- 
cial respiration practised, rhythmical traction of the tongue per- 
formed as soon as possible, pure ox} r gen inhaled and the vagus 
faradized. Tickling or irritation of the nasal mucosa is also often 
useful. If edema of the glottis supervenes, intubation or 
tracheotomy. 

If there is evidence of blood dissolution (hemolysis) venesection 
with an infusion of the alkaline sodium chloride solution mentioned 
above (to which may profitably be added a few grains of calcium 
chloride). 

For collapse and unconsciousness lowering of the head, irrita- 
tion of the skin with mustard plasters, subcutaneous injection of 
analeptics, as ether or camphorated oil, ingestion of strong coffee 
or alcohol in the form of brandy, if necessary, through the stomach 
tube. Internally the following prescription : 



? 



Lig. ammon. anisat., 

Spirit, etheris, aa 10.0 

M- Sig. 10 drops every hour, in water or gruel. 



THE COMMONER INTOXICATIONS 673 

In order to render the therapeutic indications more clear and 
the diagnosis of different forms of poisoning more simple, it has 
seemed best to include in the following the salient features of the 
symptomatology under each poison. 



ACONITE. 



The main s} r mptoms are the following: Profuse salivation Symptoma- 
nausea, vomiting, colic, diarrhea, paresthesia or anesthesia of the ° ogy 
tongue, burning in the mouth, paresthesia and anesthesia of the 
fingers and toes, mydriasis, anemia, headache, dizziness and slow 
heart action, labored breathing, coldness of the skin, convulsions 
and in severe cases complete unconsciousness and collapse. In most 
cases there is spontaneous vomiting. This should be supplemented, 
however, by gastric lavage, the use of emetics, the abundant inges- 
tion of oily or mucilaginous beverages. Internally LugoPs solution 
or tannin as follows : 

Iodi puri, 0.2 

Kali iodati, 2.0 

Aq. dest., 300.0 

M. Sig. A wineglassful every five minutes. 

Or 

Acid tannici, 4.0 

Syrup, simpl. 20.0 

Ad. dest., 200.0 

M. Sig. Tablespoonful every five minutes. 

In impeded breathing continued artificial respiration with or 
without oxygen. In collapse the ordinary analeptics — ether, cam- 
phorated oil, tincture of digitalis. 

ALCOHOL (ALCOHOLISM). 

The main symptoms of acute alcoholic poisoning are mental Acute alco- 
perturbation to the point of unconsciousness, reddening of the con- ho " sm 
junctiva and of the face, although the latter may also be pale or 
cyanotic, slow stertorous breathing, rapid pulse, cold, sticky skin, 
usually dilated pupils, frequently vomiting and involuntary passage 
of feces and lowered temperature and finally great reduction of the 
arterial tension and of the temperature, general paralysis and death 
from nervous collapse. The specific odor of the breath is in itself 
usually diagnostic. 

In chronic alcoholism there are a variety of digestive disturb- Chronic alco- 
ances partaking of the character of chronic catarrh of the pharynx, "°^ sm 






674 



THE COMMONER INTOXICATIONS 



stomach and intestine, lack of appetite, irregular bowel action, 
hemorrhoids, vomiting, usually hoarseness from chronic laryngitis 
and bronchitis^ frequently hepatic involvement (fatty liver, cirrho- 
sis of the liver), degeneration of the heart muscle and of the gen- 
eral arterial apparatus and of the kidneys. Neuritis is not uncom- 
mon, together with a variety of well known and characteristic 
functional nervous disturbances, possibly due to chronic meningitis, 
as mental hallucinations, maniacal attacks, delirium tremens. The 
general nutrition is usually seriously impaired. There is a tendency 
to obesity, great muscular weakness, anemia, marasmus. 
Treatment '-T ne treatment of acute alcoholic intoxication consists in vene- 

section, cold applications to the head, and, in case of collapse with 
a weak pulse, cardiac stimulants — black coffee by mouth being one 
of the best emergency remedies. If the respiration is seriously 
impaired, artificial respiration with or without oxygen and faradi- 
zation of the vagus nerves, vinegar enemata consisting of one part 
vinegar and three parts water are very useful. 

The treatment of chronic alcoholism consists in an educational 
course, i. e., an attempt to cure the habit, stimulation of digestion 
by bitter tonics and large doses of opium in cases of severe mental 
involvement. It is necessary to strictly individualize in the use of 
hypnotics and nerve sedatives in all cases of chronic alcoholism, and 
the treatment is largely institutional. One of the best remedies for 
the muscular tremors in delirium tremens is the hydrobromate of 
scopolamin in doses of 0.5 mg., repeated as needed. 



Symptoma- 
tology 



ALUM. 

The symptoms are those that one would expect from contact of 
an irritating salt with the lining of the upper digestive tract, that 
is, burning of the mouth and esophagus and stomach, nausea, vom- 
iting, frequently bloody; gastritis and later nephritis. 

The treatment consists in washing out the stomach with milk, 
soapy water, suspension of chalk or other mild alkalie. If the vomit- 
ing persists, ice pills; and if the gastric distress is very severe, 
tincture of opium emulsified in oil. 



Symptoma- 
tology 



AMMONIA. 

The general symptoms of local irritation of the gastro-intestinal 
and the respiratory tracts appear. The cerebral and spinal centers 
show evidence of intense irritation, very forced breathing, spasms 
in various muscles followed by instability and paralysis. In case of 
inhalation the symptoms about the respiratory tract are those of in- 
tense irritation of the mucosa, violent coughing, aphonia, dyspnea, 
choking spells with expectoration of bloody sputum. The eyes are 
also affected, there is conjunctivitis and the same symptoms of irri- 



THE COMMONER INTOXICATIONS 675 

tation of the central nervous system make their appearance. The 
urine always shows an excess of ammonia salts and evidence of 
severe irritation of the kidneys, albumin, hemoglobin, hematin, etc. 
The treatment consists in the inhalation of the fumes of vinegar, 
of ordinary steam, the drinking of lemonade or of dilute citric acid. 
For the dyspneic phenomena inhalations of oxygen with or without 
a tracheotomy. 

AMYL NITRITE. 

Profuse reddening of the face, violent beating of the carotids, 
headache, mental confusion and dizziness, sensation of oppression, 
fainting and, in extreme cases, coma. 

The treatment consists in the supplying of abundant fresh air 
and of oxygen. If the drug has been taken by mouth, gastric 
lavage and emetics. In collapse, sprinkling of the skin with cold 
water, rubbing of the body surfaces, artificial respiration. As an 
antidote against the vasomotor paralysis ergotin may be employed. 
The treatment, it will be seen is purely symptomatic. 

ANTIMONY. 

Profuse salivation and expectoration, vomiting with severe Symptoma- 
gastro-intestinal pain and dysenteric stools. Swelling and redness tol °sy 
of the mouth and upper air passages, increase in the pulse rate, 
later a slowing of the heart's action and of the respiration. The 
skin becomes cold, the patient relapses into unconsciousness, occa- 
sionally suffers from convulsions and death finally occurs from 
cardiac paralysis. Throughout this picture there are no symptoms Differentiation 
of bladder disturbances and this is an important point in the differ- from arsemc 
ential diagnosis from arsenical poisoning. 

The treatment consists in cleansing the stomach and intestine 
by lavage and enemas, even in cases of subcutaneous poisoning. In 
addition tannin preparations (for formula see index) for the pur- 
pose of forming insoluble antimony-tannin. In case no tannin is 
readily available, white of egg, milk, mucilage, oil, bicarbonate of 
soda or magnesia should be given. For the cardiac weakness 
analeptics. For the excessive vomiting ice pills, lemonade and, in 
extreme cases, morphine. 

ANTIPYRIN. 

Vomiting, atypical exanthema, loud buzzing in the ears and Symptoma- 
profuse sweating. If the overdose has been very large, somnolence, to ogy 
unconsciousness with or without convulsions and finally collapse. 

The treatment is purely eliminative and symptomatic, that is, 
cleansing of the gastro-intestinal tract by lavage and enemas, 



676 



THE COMMONER INTOXICATIONS 



analeptics for the collapse and chloral hydrate with artificial res- 
piration, preferably with oxygen, in case of convulsions. 



Gastrointes- 
tinal type 



Paralytic type 



Acute poison- 
ing 



Chemical 
antidote 



ARSENIC. 

In arsenic poisoning two types must be distinguished, the 
gastro-intestinal type and the paralytic type. In the former the 
symptoms usually appear within an hour after the poisoning has 
occurred. A feeling of constriction about the pharynx, singultus, 
great thirst, dryness of the mouth and pharynx, difficulty in swal- 
lowing, severe colicky pain in the abdomen with vomiting, rice 
water stools and tenesmus, oliguria with blood and casts, occa- 
sionally sugar and later an arsenic reaction; dizziness, headache, 
pain in the limbs, low blood pressure^ irregular pulse, cyanosis and 
cold extremities, followed by fainting spells and parasthesia, clonic 
and tonic spasms, finally general paralysis and coma. Occasionally 
the mucous membranes become affected very soon, leading to a 
stomatitis, laryngitis and bronchitis. 

In the paralytic type many of the gastro-intestinal symptoms 
are frequently absent. A paralytic syndrome about the central 
nervous system and the heart with spasms and collapse almost im- 
mediately supervenes. A very characteristic symptom in all forms 
of arsenic poisoning is the odor of garlic about the breath and 
perspiration. 

The treatment of acute arsenic poisoning consists in inducing 
evacuation of the swallowed poison, even though violent vomiting 
may have spontaneously occurred. Of emetics apomorphine 0.01 g. 
hypodermically, or ipecac in the form of the powdered root every 
ten minutes until the desired effect is produced. Tartar emetic, 
however, should never be given. If possible, lavage of the stomach 
should be instituted and retching, and vomiting should not be con- 
sidered contra-indications to this measure. 

Cold water should be administered in large quantities. The 
chemical antidote is hydrate of iron (ferri hydro-oxydati). This 
should be suspended in water and 2 to 3 tablespoonsful given every 
ten minutes. It is important to remember that the preparation 
should be fresh. 

If the ingredients for preparing the ferric hydrate are not im- 
mediately available, the aqueous solution of the acetate (liquor 
ferri acetatis), available in any drug store, should be administered 
frequently in the dose of 15 to 30 minims. So much should be 
remembered that at least 20 times as much of iron should be intro- 
duced as arsenic has presumably been swallowed; one rarely can 
give too much iron, so that # it is better to err in the direction of an 
over dose than an under dose of the latter. Burnt magnesia stirred 
up with 15 to 20 volumes of water may also be used in combination 



THE COMMONER INTOXICATION'S 



677 



with a purgative. In case of collapse the ordinary symptomatic 
treatment, mustard plasters to the spine, warm blankets, energetic 
friction of the surfaces of the body, stimulating beverages, analep- 
tics, etc. 

In chronic poisoning with arsenic we have a gastro-enteritis 
usually associated with some fever, lack of appetite, nausea, a feel- 
ing of pressure in the epigastric region, vomiting of mucus and 
bile, laryngitis, bronchitis, a tendency to gingivitis with gangrene, 
various inflammatory affections of the mucous membranes, loss 
of hair, characteristic skin eruptions often with melanemia and the 
characteristic pallor, headache, lack of energy, a variety of motor 
and sensory disturbances, multiple neuritis and arsenical paralysis. 

The treatment consists in stopping the intake of arsenic, what- 
ever its source may be, and corresponds otherwise with the treat- 
ment of the acute form. Energetic diaphoretic medication, espe- 
cially by hot baths and rapid elimination of the arsenic by means 
of purgatives and diuretics. In addition, of course, the symptom- 
atic treatment of the various manifestations of the chronic 
poisoning. 



Chronic 
soning 



poi- 



tology 



ATROPIN (BELLADONNA AND HYOSCYAMIN). 

The main symptoms are great dryness of the mouth and throat, Symptoma- 
hoarseness and difficulty in swallowing. The face is usually very 
red ? the pulse rapid. The skin is dry and occasionally shows urti- 
caria. The pupils are dilated and rigid and a variety of visual dis- 
turbances make their appearance (diplopia, amblyopia, amaurosis). 
There is much headache and dizziness. Occasionally ischuria. 
Mental symptoms soon put in their appearance, delirium, hallucina- 
tions, maniacal attacks, choreiform movements, tremors, spasms, 
parasthesias. In very severe cases loss of consciousness, paralysis 
of the sphincters, stertorous breathing and coma. Death occurs 
through respiratory or general central paralysis. 

The treatment consists in energetic lavage of the stomach and 
the administration of emetics. Tannic acid or LugoFs solution 
(see page 673) should be given. Pilocarpin is said to be a chemical 
antidote, but its action is rather doubtful. It can do no harm, 
however, to administer it in the following form : 

Pilocarpin hydrochlorat, 0.1 

Aq. dest., 10.0 

M. Sig. Inject an hypodermic needleful every 
fifteen minutes. 

Particular care should be observed in the use of morphine. It Danger of 
should never be given in large doses but only in small doses fre- morp me 



Chemical 
antidote 



678 



THE COMMONER INTOXICATIONS 



quently repeated. If the cerebral symptoms are very severe, a few 
whiffs of chloroform or 15 to 20 grains of chloral hydrate in water 
by mouth should be given. 

In addition, cold applications to the head and in case of threat- 
ened collapse or coma, wine, coffee, ammonia, camphor injections, 
ether injections. If the visual disturbance and the mydriasis are 
marked, physostigmin applied locally as follows : 

Physostigmin salicylate, , 0.04 

Aq. dest, 10.00 

M. Sig. Three drops to be dropped into the 

conjunctiva every hour until the desired effect 

is produced. 



Symptoma- 
tology 



BARIUM. 

The main symptoms are nausea, salivation, severe gastritis with 
vomiting and abdominal pains and profuse diarrhea, later convul- 
sions, occasionally paralysis, bradycardia, anginal attacks, palpita- 
tion, great rise in the blood pressure, dizziness, tinitus aurium. 
This picture, it will be seen, closely simulates lead poisoning, only 
that in the latter the vomiting and diarrhea are not so apt to dom- 
inate the picture. 

The treatment consists in the administration of abundant quan- 
tities of albumin water and the production of emesis by apomor- 
phine hypodermically. Lavage of the stomach with a 1 per cent, 
magnesium sulphate solution is useful, or sodium or magnesium 
sulphate may be given by mouth in large doses. 

In ease the barium has been swallowed some time ago, so that 
there is danger of erosion of the stomach, the stomach tube and 
emetics should, of course, not be used and one should content one's- 
self with giving a large quantity of sodium sulphate every day. If 
the convulsions are severe a little chloroform by inhalation or 
chloral hydrate in appropriate dosage. 



Symptoma- 
tology 



BEE STINGS. 

The well known local symptoms consist in circumscribed inflam- 
mation and edema and, in severe cases, of lymphangitis. If many 
bee stings have been sustained, the patient may succumb after 
fainting, vomiting, delirium. 

The treatment consists in the careful removal of the sting. The 
place should be touched with ammonia and the skin dressed with a 
little moist disc of raw potato, after that an ordinary carbolic 
vaselin may be applied with a lead water dressing; or in case the 
stings are in the face, with ice compresses. If the whole body is 



THE COMMONER INTOXICATIONS 679 

covered with stings the patient should be put into an alkaline bath 
containing about a kilo of ordinary washing soda to the bath-tubful. 

BELLADONNA— SEE ATROPIN. 
BOTULISM— SEE FOOD POISONING. 
BROMIN AND BROMIDES (BROMISM). 

The local symptoms following the inhalation of bromin vapors Local symp- 
or the ingestion of bromin water are those of irritation and necrosis 
of the mucous membranes coming in contact with the bromin. 
After absorption of the bromin has occurred, symptoms of nervous 
depression and of narcosis appear. If bromin is swallowed there is General symp- 
vomiting, diarrhea and frequently collapse. Bromin vapor poison- 
ing manifests itself by narcosis preceded by a period of excitation, 
general anesthesia, cardiac collapse. The prolonged use of bro- 
mides produces symptoms of nervous depression, somnolence, head- 
ache, emaciation and a typical eruption. 

The treatment of acute bromin poisoning, provided the bromin 
preparation is swallowed, consists in the administration by mouth 
of starch paste, or flour and milk in the strength of 1 to 10, albu- 
min water and ? above all things, alkalies. A dilute carbolic acid 
solution is particularly suitable for gastric lavage. The treatment Bromoform 
of 'bromoform poisoning, aside from the removal of the swallowed 
drug by gastric lavage and apomorphine injections, is symptomatic. 
In chronic bromism the first step, of course, is the cessation of 
bromide medication. Arsenic internally and bathing of the skin 
with dilute alkaline solutions. 

CALCIUM (LIME SALTS). 

Aside from the chemical injury to the mouth, pharynx and 
esophagus, there are symptoms of irritation of the vasomotor cen- 
ters followed later by paralysis of the same. In case lime water or 
slaked lime has been swallowed oil, milk, egg lemonade or lemon 
juice should be administered, followed by gastric lavage with a 
dilute solution of citric acid. 

CARBOLIC ACID. 

About the mouth and lips whitish burns will be seen. There is Symptoma- 
usually an initial collapse followed by delirium and a stage of ex- ° ogy 
citation with dizziness, tinnitus aurium, contracted pupils, sweat- 
ing. The pulse in the beginning is slow. Later it becomes accel- 
erated. The breathing is usually stertorous, the skin cool and livid. Urinary 

The peculiar odor of the urine that is usually light -yellow but 
may also be bloody or brownish-red, turning dark-green after ex- 
posure to air, and the carbolic odor of the vomit usually facilitate 
the diagnosis. 



signs 



680 



THE COMMONER INTOXICATIONS 



A gastric lavage should be practised with a suspension of pre- 
cipitated chalk in water. Emetics should not be administered. As 
soon as the patient can swallow, syrupus calcis should be admin- 
istered for the purpose of forming phenol calcium, which is readily 
eliminated. Albumin water, milk and oil may be administered. 
Colonic flushings should be practised. The collapse should be 
treated with analeptics and if respiratory failure threatens, artifi- 
cial respiration, venesection and infusion of normal salt solution 
should be instituted. 



Symptoma- 
tology 



CARBON DIOXIDE. 

This form of poisoning is apt to occur in certain industries in 
which large amounts of carbon dioxid (C0 2 ) are manufactured 
and in which arrangements for proper ventilation are not made. In 
the beginning the patients complain of an acid taste with tickling 
and prickling of the mucosa of the mouth and an irritative cough. 
There is often spasm of the glottis. Vomiting and diarrhea, ster- 
torous breathing, dizziness, high blood pressure with a slow pulse 
are common symptoms. There is usually a short period of excite- 
ment followed by unconsciousness, cyanosis and death from coma 
with terminal convulsions. 

The treatment consists in the supplying of fresh air, artificial 
respiration, rhythmic traction of the tongue, rhythmic insufflation 
of compressed oxygen, occasionally in case of severe spasm of the 
glottis, after a preliminary tracheotomy. The collapse phenomena 
should be treated by irritation of the body surfaces with cold appli- 
cations, the administration of alcohol and the injection of 
analeptics. 



Symptoma- 
tology 



CARBON MONOXIDE (ILLUMINATING GAS). 

The main symptoms are a throbbing headache with tinnitus 
aurium, dizziness, redness of the face, high blood pressure with pal- 
pitation and a slow pulse, later with a rapid, small pulse and in the 
terminal stages again with a slow, irregular heart. There is usually 
nausea and vomiting, deep, stertorous breathing, later fainting and 
occasionally convulsions with relaxation of the sphincters of the 
body and involuntary excretions. The temperature is usually re- 
duced in advanced stages. The diagnosis can usually be made in 
case an individual is found in a comatose condition in a close room 
with a very much reddened face, stertorous breathing, normal 
pupils and a low temperature, provided always that the odor of 
alcohol cannot be discovered on the breath. 

The treatment consists in immediate removal from the poison 
chamber and the supplying of plenty of fresh air. Artificial res- 
piration with oxygen and rhythmic traction of the tongue should be 



THE COMMONER INTOXICATIONS 



681 



performed. This treatment should be kept up for many hours, as 
in the case of drowning. Irritation of the body surfaces, faradiza- 
tion of the vagus, cool applications to the head should be practised. 
Black coffee should be administered and analeptics given hypoder- 
mically. If there is very much cyanosis a small amount of blood 
may be withdrawn by venesection, followed, in very severe cases, by 
the intravenous infusion of the alkaline-saline solution given else- 
where. 

CHEESE POISONING— SEE FOOD POISONING. 
CHLORAL HYDRATE. 

In acute chloral poisoning there are symptoms of irritation of Acute poi- 
the gastro-intestinal canal with pain, nausea and vomiting, occa- somn £ 
sionally gastro-intestinal hemorrhages. The epiglottis and the 
pharynx are apt to be swollen ; there are visual disturbances ; urti- 
oaria and deep somnolence combined with cardiac weakness, cyano- 
sis, reduction of the temperature and retardation of breathing are 
common symptoms. Occasionally, if a large overdose is taken, 
there is sudden collapse and death. 

In chronic chloral poisoning the gums become swollen, vesicles Chronic poi- 
appear on the tongue. There are severe digestive disturbances, s nmg 
usually with icterus and diarrhea, various cutaneous lesions, great 
prostration and emaciation, hallucinations, delirium and palpita- 
tion. Death occasionally occurs from cardiac collapse. 

The treatment of acute chloral hydrate poisoning with collapse 
consists in artificial respiration with compression of the precordial 
region. In the comatose form sodium bicarbonate should be given 
internally. The stomach should be thoroughly washed and normal 
salt solution infused directly into the veins. If the respiration is 
very much impeded, artificial respiration with oxygen and faradiza- 
tion of the vagus should be instituted, the body kept warm, analep- 
tics (camphor, ether) administered hypodermically. In the chronic 
form every effort should be made to break the patient of his drug 
habit, first, by the substitution of less harmful hypnotics for chloral 
and gradual withdrawal of all sleep-producing medicines. At the 
same time appropriate general treatment of the nervous system, a 
strengthening diet, appropriate hydrotherapy and a course of 
arsenic. 



CHLORATE OF POTASH. 

This drug is commonly used in solution as a gargle and a mouth Symptorna- 
wash and occasionally acute poisoning occurs from swallowing too ' ogy 
much of the preparation. The main symptoms are nausea, obsti- 
nate vomiting, pain in the abdomen with diarrhea, low blood press- 
ure, hemolysis, dyspnea and cyanosis. Similar symptoms, only less 



682 



THE COMMONER INTOXICATIONS 



severe, are encountered in the subacute cases. Here the liver and 
spleen are commonly swollen, grayish-violet spots appear on the 
skin or an icteric discoloration. The blood contains methemaglobin 
and degenerative forms of blood corpuscles are found usually with 
some leucocytosis. Uremic symptoms are not uncommon. Death 
occurs from central paralysis. 

The treatment consists in rapid evacuation of the swallowed 
drug by gastric lavage, colonic flushings and purgatives. Venesec- 
tion should be performed and an alkaline-saline infusion made. 
(See page 671). Abundant water or a dilute solution of soda bicar- 
bonate should be administered by mouth and all acids avoided. 
Oxygen should be given by inhalation. If there is no collapse pilo- 
carpin should be injected, in order to facilitate elimination of the 
drug through the saliva. 



Local symp- 
toms 



Thiosulphite 
of sodium 



CHLORIN (HYDROCHLORIC ACID). 

The symptoms following the inhalation of chlorin gas or of the 
fumes of hydrochloric acid are locally profuse irritation of the 
mucous membranes of the upper respiratory tract with all the self- 
evident sequelae. In chronic inhalation of these vapors there is a 
bronchial catarrh, bronchial pneumonia and usually severe digestive 
disturbances with emaciation. If very large quantities are inhaled 
at once sudden death may occur. 

The treatment consists in the inhalation of water vapors or, 
better still, of a spray of a dilute sodium bicarbonate solution ; the 
supplying of plenty of fresh air and the administration by mouth 
of a dilute solution of thiosulphite of soda (natr. subsulfuros.) in 
the strength of about 1 to 20, of which 2 tablespoonsful can be 
taken at a time, to be repeated every 10 to 15 minutes until five or 
six doses are taken. If chlorin water has been drunk, gastric lav- 
age, emetics, albumin water, milk, mucilaginous solutions. If 
hydrochloric acid has been swallowed, then, of course, the ordinary 
antacid treatment combined with emetics and gastric lavage. 



Local symp- 
toms 



Poisoning by 
Inhalation 



CHLOROFORM. 

The symptoms of local irritation from contact of the drug with 
the mucous membranes of the mouth and throat are not character- 
istic but consist merely in ordinary irritative phenomena. If the 
drug is swallowed there is a corresponding irritation of the gastro- 
intestinal tract, with vomiting and occasionally bloody diarrhea, 
followed by narcosis. In poisoning from inhalation in the course 
of artificial anesthesia, there is first a period of excitation and ab- 
normal muscular tension with dilated pupils, later an anesthetic 
period with lowered blood pressure and relaxation of the muscle 
•pasm and of all reflexes, a contracted pupil and complete uneon- 



THE COMMONER INTOXICATION'S 683 

sciousness. The toxic or paralytic stage is characterized by respira- 
tory failure, great reduction in the pulse frequency and dilatation 
of the pupils and occasionally sudden cardiac failure. In the latter 
case the face suddenly becomes pale, whereas in chloroform anesthe- 
sia due to failure of the respiration without serious involvement of 
the cardiac mechanism, the face remains very red, the veins of the 
face and throat swollen and the lips cyanotic. An occasional sequel 
of chloroform anesthesia is a condition closely resembling acute 
yellow atrophy of the liver and the symptoms of this accident 
should be looked for in post-operative complications after chloro- 
form anesthesia, provided the surgical conditions do not explain the 
syndrome. 

The treatment of chloroform poisoning following the swallow- 
ing of the drug consists in energetic lavage of the stomach and the 
administration of emetics, apomorphine hypodermically, also colonic 
flushings. If the patient is seen before anesthesia has occurred 
stimulating drugs, coffee or alcohol should be given and, if there is 
threatened respiratory failure, artificial respiration should be 
instituted. 

In accidents occurring on the operating table during chloroform Anesthesia 

accidents 

narcosis the steps to be adopted are the following : 

Immediate cessation of the chloroform inhalation, depression of 
the head, rhythmic traction of the tongue (about fifteen times a 
minute) with artificial respiration, methodic cardiac compression 
and rhythmic insufflation of oxygen. The surfaces of the body 
should be thoroughly rubbed and the body kept warm. Intraven- 
ously a dilute solution of adrenalin may advantageously be admin- 
istered, or camphor given subcutaneously. Care should, of course, 
be taken to prevent mechanical closure of the glottis by drawing the 
tongue forward. Faradization of the vagus nerve may be tried, but 
it is usually superfluous and rarely effective. 

COCAINE. 

In acute poisoning there is sudden pallor of the face with dizzi- Acute poi- 
ness, a feeling of weakness in the extremities with a small rapid somng 
pulse, irregular or Cheyne-Stokes respiration^ occasionally symp- 
toms of cerebral excitation manifested by great hilarity, loquacity, 
hallucinations, occasionally with delirium and maniacal symptoms. 
Here and there a convulsive form of cocaine poisoning is seen with 
epileptiform seizures, choreiform movements and opisthotonos. If 
the drug is swallowed in poisonous doses there is a feeling of dry- 
ness in the mouth and throat, difficulty in swallowing, vomiting, 
abdominal pain, rapid heart action with palpitation and precordial 
oppression, visual disturbances, occasionally progressing to amau- 
rosis, with dilated and rigid pupils ; sometimes glycosuria and often 



684 



THE COMMONER INTOXICATIONS 



complete suppression of the urine, followed by a condition of nar- 
cosis and coma. 

Amyl nitrite The treatment of this intoxication consists in the administra- 

tion of amyl nitrite by inhalation or, in extreme cases, of analeptics, 
camphorated oil, ether, administered subcutaneously ; counter- 
irritation over the heart and epigastrium, irritation of the body 
surfaces. If the drug is swallowed, gastric lavage. During the 
stage of excitation and convulsions inhalations of chloroform or 
ether or chloral hydrate by mouth. If there is danger of respira- 
tory f ailure, much cyanosis, then artificial respiration and rhythmic 

Prophylaxis insufflation of compressed oxygen. The prophylaxis, of course, 

consists in avoidance of large doses of cocaine, and great care in its 
employment, particularly in cases in which the existence of an 
idiosyncrasy against the drug has not been established. More than 
0.08 g. of cocaine should never be injected^ and it is always best to 
first compress the point of injection in order to devascularize the 
area. 



Acute poi- 
soning 



COLCHICIN. 

An overdose of colchicin produces a gastritis and enteritis with 
bloody diarrhea and bloody vomiting. The skin becomes cold and 
the body temperature gradually reduced. There is aphonia, twitch- 
ing of the muscles and general tremor, occasionally tonic and clonic 
convulsions ; consciousness is usually maintained and death gen- 
erally occurs through respiratory failure. 

The treatment consists in rapid evacuation of the drug by gas- 
tric lavage, colonic flushings and drastic purgatives, castor oil, cro- 
ton oil. Especially useful is lavage of the lower bowel with a 
tannic acid solution of the strength of 10 to 300, to which a few 
drops of laudanum may be added in order to facilitate the retention 
of the tannic acid. Tannin should also be given by mouth. 

The following prescription is useful: 

Acid tannic, 5.0 

Extr. opii aq., 0.2 

Aq. dest., 200.0 

M. Sig. A tablespoonful every five minutes. 

Abundant warm water should be given by mouth or, if the vom- 
iting is very profuse, ice pills. The diarrhea should be controlled 
by opiates, collapse phenomena by analeptics. 



Local symp- 
toms 



COPPER AND COPPER SALTS. 

Locally there is usually considerable irritation with a metallic 
taste and the vomiting of greenish or bluish masses, severe saliva- 






THE COMMONER INTOXICATIONS 685 

tion, abdominal pain, colic ? and painful diarrhea. The stools at General symp 
first are bloody and later become black from the presence of copper 
sulphide. There is usually also some hematuria. About the cen- 
tral nervous system there appear severe headache, dizziness, som- 
nolence, later convulsions and various paretic phenomena. The 
pulse is usually small, respiration increased. At the expiration of 
a few days icterus is apt to appear. In chronic copper poisoning or 
in subacute cases there is a chronic gastritis and frequently intes- 
tinal ulceration. The abdominal pains are exceedingly severe and 
colicky in character, but are distinguished from the pains of lead 
colic by the absence of constipation and the frequent evacuation of 
greenish or yellowish stools containing much mucus and blood. 
The abdomen is usually distended and exceedingly sensitive to 
pressure. 

The treatment consists in the rapid evacuation and neutraliza- 
tion of the swallowed poison by the administration of emetics and 
gastric lavage or the drinking of a very dilute solution of potassium 
ferrocyanide, or of milk of magnesia diluted with water. Milk or 
white of egg should be given promptly but no fats of any kind. 
Burned magnesia, sugar of milk or a suspension of animal charcoal 
1 to 100 in water are all useful. Persistent vomiting should be 
treated with ice pills and counter-irritation over the epigastrium; 
the colicky pain and the tenesmus by morphine or opium, admin- 
istered either by mouth, hypodermically or in the form of a starch- 
laudanum enema. 

DIGITALIS (STROPHANTHUS). 

After an overdose of digitalis or of strophanthus or in the cumu- Symptoma- 
lative effect (that occasionally results from the administration of ° ogy 
these drugs, where there is defective elimination), dryness of the 
throat, nausea, vomiting, severe thirst, colic, usually headache and 
insomnia, palpitation, great reduction in the rapidity of the pulse 
rate, high blood pressure at first with low blood pressure later, 
anginal attacks with a feeling of great oppression in the precor- 
dial region, symptoms of delirium, convulsions, visual disturbances 
progressing occasionally to myopia, a reduced urinary excretion and 
a feeling of great lassitude all put in their appearance. Death 
occurs in syncope or in coma preceded by a delirious state with or 
without convulsions. 

The treatment consists in stopping the use of the drug and 
administering analeptics (see index), especially alcohol. Vaso dila- 
tors like amyl nitrite intravenously and erythroltetranitrate by 
mouth are useful. Usually there is vomiting, but, if it does not 
occur spontaneously, it is well to stimulate emesis by tickling the 
palate. Absolute quiet is an imperative rule and the patient should 



686 



THE COMMONER INTOXICATIONS 



avoid all exertion after the first symptoms of the intoxication have 
made their appearance. If syncope and collapse threaten, venesec- 
tion with intravenous infusion of physiological salt solution, fol- 
lowed by the use of black coffee, alcoholic beverages and injections 
of camphor or ether. 



Symptoma- 
tology 



Chronic poi- 
soning 



ERGOT (ERGOTISM). 

The main symptoms are referred to the gastrointestinal tract 
and consist in nausea, eructations, vomiting, abdominal pain and 
diarrhea. The skin is usually very pale and formication frequent. 
There is headache, dizziness, great muscular weakness and a re- 
tardation of the pulse; in very severe cases delirium, unconscious- 
ness and coma. In pregnant women abortion is very apt to occur. 
Death occurs from cardiac and respiratory paralysis. 

In the more chronic forms there are a variety of ocular symp- 
toms, headache, paresthesias, especially in the extremities, notably 
the fingers and toes, a feeling of lassitude and of mental hebetude, 
tonic and clonic convulsions, often lasting for hours, epileptiform 
seizures followed by contractures and atrophy. Occasionally spas- 
modic manifestations are witnessed about the cranial nerves. The 
syndrome of tabes may be imitated. The psychosis is very marked. 
The action of the heart is usually retarded, later, on account of the 
paresis of the vagus, accelerated. Trophic disturbances, loss of 
hair, furunculosis, cachexia and marasmus occur in extreme cases. 
There is also a gangrenous form of chronic ergotism that is par- 
ticularly horrible. 

The treatment of acute ergot poisoning consists in the evacua- 
tion of the gastro-intestinal tract by lavage, emetics and colonic 
flushings, followed by the administration of tannin. Salicylates 
are occasionally of value in the form of salicylic acid or of salol 
given in ordinary doses. The treatment of chronic ergotism is 
purely symptomatic, after the source of the poison has been 
removed from the diet. 



Poisoning from 
inhalation 



ETHER. 

Ether poisoning is usually witnessed in the course of narcosis. 
In contra-distinction to chloroform poisoning there is no reduction 
of the blood pressure, rather an increase in the arterial tension. 
The face is congested, the breathing irregular, finally stopping 
altogether; occasionally arrest of the heart action. Death usually 
supervenes from pulmonary edema or pneumonia. 

The maximum of air should be immediately supplied, the chest 
sprinkled with cold water and the surface of the whole body ener- 
getically rubbed; artificial respiration practised, preferably with 
the aid of pure oxygen combined with rhythmic traction of the 



THE COMMONER INTOXICATIONS 687 

tongue and faradization of the vagus. If much secretion has en- 
tered the upper air passages, tracheotomy must be performed. As 
soon as breathing movements have been re-established, the injection 
of 1 to 2 mg. of strychnia sulphate hypodermicallv. Forced res- 
piration may further be stimulated by smelling ammonia. 

Etherism is very rare and the only treatment is educational, 
i. e., the cure, preferably in an institution, of the ether habit. 

FISH POISONING— SEE FOOD POISONING. 
FOOD POISONING (BOTULISM). 

Under the above heading are included a variety of toxic syn- Etiology 
dromes attributable to poisoning with meat, fish, oysters, cheese, 
etc. Some of these forms of intoxication are due to putrefactive 
toxins of unknown etiology, others to specific toxins produced by 
the bacillus enteritidis or the bacillus coli communis, or to a pe- 
culiar anaerobic spore-forming bacillus that has been called bacillus 
botulinus. The latter is a pathogenic saprophyte that produces a Bacillus 
toxin in the meat presumably before the meat is swallowed, not botulinus 
after it has reached the stomach and intestine. This toxin has a 
special affinity for the nervous system. Against this bacillus an 
antitoxin has been prepared that seems to be of some value. On 
account of the rapidity of the disease^ it is, of course, not procurable 
on short notice, so that its practical value for therapeutic purposes 
is very small. 

Most of the epidemics of food-poisoning that are attributed to Ptomaines 
the ptomaines of putrid meat are caused by pathogenic bacteria, of 
which the bacillus enteritidis above mentioned is the principal one. 
Here again the liberation of the specific toxins usually occurs before 
the meat is eaten and not after it enters the digestive tract. 

The treatment is purely symptomatic after removal of the of- 
fending material from the gastro-intestinal tract. Gastric lavage, 
emetics and purgatives should be given. An attempt at intestinal 
antisepsis should later be made by the use of calomel, resorcin, salol 
or sulphocarbolates, bile or sodium glycocholate. In the choleri- 
form variety the excessive vomiting should be controlled by a few 
drops of chloroform, small pieces of ice and injections of morphine, 
with laudanum-starch enemata. Collapse should be treated with 
hot, strong coffee and brandy, analeptics subcutaneously, hot baths 
and in extreme cases with infusion of normal salt solution. 

HYOSCYAMUS— SEE ATROPIN. 
IODINE AND IODIDES. 

The inhalation of vapors of iodine results in profuse irritation Local symp 
of the upper respiratory passages and of the conjunctivas. Swal- 
lowing tincture of iodine produces a brown discoloration of the 



688 



THE COMMONER INTOXICATIONS 



mucous membranes of the mouth and the vomiting of brown, occa- 
sionally blue (starch in the stomach) masses. In addition severe 
irritation, even necrosis of the pharynx and esophagus, very violent 
abdominal pain, albuminuria, hemoglobinuria, later often anuria 
and collapse. Chronic iodism, following the administration of large 
doses of iodides, produces a metallic taste in the mouth with saliva- 
tion and coryza, as well as conjunctivitis and occasionally edema of 
the lids. Very frequently asthmatic symptoms make their appear- 
Iodine acne ance and larynx edema is not uncommon. The typical iodine acne 

and pemphigus attributable to iodine intoxication are frequently 
seen. In extreme cases albuminuria and hemoglobinuria occur. 
There is usually emaciation and pallor. In doubtful cases the diag- 
nosis must hinge upon the recognition of iodine in the saliva and in 
the urine. 

The treatment consists, in acute cases, in the evacuation of the 
swallowed tincture of iodine by gastric lavage with sodium thiosul- 
phate solution and the administration of albumins and starch. It 
is usually most practical to administer some white of egg and a 
little starch paste at once, then to remove the iodine albuminate and 
iodine starch compounds that have been formed, by means of gas- 
tric lavage, and finally to administer the sodium thiosulphate solu- 
tion in the strength of 10 to 200 and in the dose of 2 tablespoonsful 
every ten minutes until five or six doses have been taken. In addi- 
tion to this, sodium bicarbonate should be administered. The iodine 
burns on the mucous membranes or on the skin should be treated 
locally with solutions of sodium thiosulphate. 



Absorption 



Symptoma- 
tology 



IODOFORM. 

Following the absorption of Iodoform from wounds, joints, 
serous cavities the following syndrome occasionally appears : 

Severe headache, insomnia, mental depression, melancholia, 
paranoia, hallucinations and catatonic psychoses, with a small and 
rapid pulse. In children the syndrome of a meningitis with fever 
may be imitated. Often iodine is found in the urine and the charac- 
teristic iodoform odor will be recognized in the breath. 

The treatment consists in the removal of the iodoform from the 
wounds and the administration of alkalies as, for instance, a solu- 
tion of sodium bicarbonate in water in the strength of 1 to 15, a 
tablespoonful to be administered every ten minutes. 



Symptoma- 
tology 



IRON. 



The swallowing of an overdose of iron salts leads to great irri- 
tation of the gastro-intestinal tract^ as manifested by vomiting, 
colic and diarrhea, with the evacuation of black stools. The treat- 
ment consists in the administration of apomorphine hypodermically, 



THE COMMONER INTOXICATIONS 689 

thorough gastric lavage, the administration of albuminous fluids 
like milk, white of egg, mucilage and magnesium carbonate or 
sodium carbonate in large doses by mouth, both as a chemical anti- 
dote to the iron preparation and as a laxative. If gastro-enteritis 
follows, the ordinary treatment appropriate to this condition should 
be instituted. 

LEAD. 

The main symptoms of acute lead poisoning are general erosion Acute poi- 
of the mouth and pharynx with a grayish discoloration of the sonin S 
mucosa that has been exposed to the lead salt, a metallic taste and 
salivation, vomiting of grayish-white material, colic, constipation 
or bloody diarrhea, itching, a slow, weak pulse, dizziness, headache, 
anesthesias, paresthesias and paralytic phenomena about the 
extremities and, in extreme cases, stupor, unconsciousness, 
convulsions. 

The treatment consists in rapid evacuation of the gastric con- 
tents both by emetics (apomorphine hypodermically) and gastric 
lavage with a 1 per cent, magnesium sulphate solution; further 
colonic flushings with warm solutions of magnesium sulphate. The 
patient should be instructed to swallow albuminous liquids like 
albumin water, white of egg, milk. As a laxative, sodium or mag- 
nesium sulphate should be administered. More rapid elimination 
of the lead salts can be promoted by the administration of iodide of 
potash. For some time after the acute poisoning the patient should 
be kept on a, liquid diet and opium administered for the pain. 

In chronic lead intoxication we see the characteristic blue line Chronic poi- 
along the gums and the typical emaciation with anemia (cachexia soning 
saturnina) , with a swollen parotid, nausea and fever. The lead 
colic is very characteristic. It is often accompanied by high blood 
pressure and asthmatic attacks with very obstinate constipation, 
occasionally vomiting. The pulse is usually slow, the abdomen con- 
tracted and very hard. Sometimes there is tenesmus and ischuria, 
arthralgia, circumscribed areas of anesthesia, amblyopia, amaurosis, 
severe headache (encephalopathy saturnina) with delirium, depres- 
sion, occasionally maniacal attacks, convulsions (eclampsia satur- 
nina) and coma. Later the typical paralysis of chronic lead poison- 
ing involving chiefly the extensor group on the radial side of the 
forearm, with muscular atrophy. The cranial nerves may be in- 
volved. Finally there occurs the characteristic renal sclerosis and 
the formation of urate concretions (lead gout). 

In the treatment of this form of lead poisoning, which may Treatment 
either follow acute lead intoxication, especially if large quantities 
of lead have been swallowed, or may occur in individuals continual- 
ly exposed to the fumes of lead or continuously handling lead, the 



690 



THE COMMONER INTOXICATIONS 



elimination of the retained lead salts is best brought about by iodide 
of potash and diaphoretic treatment. The dosage of the former 
will have to be somewhat regulated according to the effect. For 
the severe colicky pains opium or morphine or a little chloroform 
internally, half a milligram of scopolamin hydrobromate, or one 
milligram of atropin sulphate are frequently of value in cutting 
6hort the attacks. Amyl nitrite by inhalation has also been found 
useful, in as much as the colicky pains are presumably due to a 
paroxysmal hypertension of the abdominal arteries. Hot applica- 
tions or Priesnitz compresses should, of course, be applied to the 
abdomen. As soon as the attack of colic is over, a brisk purgative, 
preferably a dose of castor oil, of sulphate of sodium or of magne- 
sium should be given. The bowels should be kept open all the time 
by the use of some mineral water containing sulphate of mag- 
nesium. The cachectic condition, the arthralgias, the anesthesias, 
the amaurosis and the headache, as well as the paralytic phenom- 
ena must be treated symptomatically, but they usually disappear 
after complete elimination of the offending lead. 



Acute poi- 
soning 



Mercurialism 



Treatment 



MERCURY (CORROSIVE SUBLIMATE). 

After swallowing a mercury salt acute poisoning manifests it- 
self by a metallic taste in the mouth and eruptive phenomena about 
the mucous membrane of the mouthy pharynx, esophagus and stom- 
ach. There is vomiting of whitish or bloody material and bloody 
diarrhea with tenesmus, ischuria, anuria, the excretion of ,albu- 
min and blood in the urine. The pulse becomes small and the 
patients break out in a cold sweat and are apt to collapse. Con- 
sciousness is rarely impaired, even in cases that rapidly progress 
to a fatal issue. If the poison is not promptly eliminated, inflam- 
mation of the salivary glands, stomatitis, gingivitis with great fetor, 
swelling of the tongue, edema of the glottis occur. Dysentery, coli- 
tis, as well as anuria, may also occur in cases in which the mer- 
cury is not swallowed but is introduced into the body through other 
channels. In chronic mercury poisoning (mercurialism) there is 
chronic stomatitis with ulceration of the mucous membranes of 
the mouth, necrosis of the jaw, gingivitis, a general cachexia with 
less of subcutaneous fat and atrophy of the skin. In addition a 
variety of digestive disturbances, nephritis, often a tremor, mus- 
cular paresis and impairment of the intellect. 

The treatment of acute mercurial poisoning consists in the im- 
mediate administration of albuminous fluids and of milk. After 
the incorporation of the latter vomiting should be stimulated, either 
mechanically, by irritation of the pharynx, or by the hypodermic 
administration of apomorphine. If there is much blood in the vomit 
gastric lavage, on account of the danger of perforation, should not 



THE COMMONER INTOXICATIONS 691 

be performed. If the patient is seen very soon after the poison 
has been swallowed and if the vomitus is not bloody, then lavage 
of the stomach with a suspension of magnesia usta in water should 
be practised. Table salt should not be administered as long as 
any mercury is present in the gastro-intestinal tract. The col- 
lapse and the pain should be treated symptomatically with analep- 
tics and, if possible, the anuria should be overcome by means of 
relaxing warm baths. If constipation supervenes the bowels should 
be cleansed by means of enemata but not by the use of purgatives. 
The best mouth wash for the stomatitis is a dilute solution of am- 
monium acetate and a gargle of chlorate of potash in dilute solu- 
tion. 

In order to prevent the development of chronic mercurialism in Prophylaxis of 
industries necessitating contact with mercury salts or the vapors of merc uria!lism 
mercury most rigid cleanliness of the mouth, the teeth and the 
gums should be practised. Self-evidently, too, proper ventilation 
of the workshop should be enforced. As soon as the first symptoms 
of mercurialism appear the subject should immediately be re- 
moved from contact with the mercury preparations. Iodide of 
potash may be administered internally. The treatment generally, 
however, is symptomatic and tonic. 

MUSHROOM POISONING (MYCETISM). 

The diagnosis must hinge either upon the knowledge of the Diagnosis 
ingestion of mushrooms or the discovery of pieces of mushrooms in 
the vomit or in the stools. The symptomatology, of course, largely 
depends upon the kind of poisonous mushroom that has been eaten. 
The most severe and the most characteristic form of mushroom 
poisoning is due to intoxication with muscarin. Here atropin sul- 
phate, 1 mg. subcutaneously, is almost specific. In forms in which 
there is cerebral excitation atropin is contra-indicated and mor- 
phine should be given instead. The latter form is called cerebral Cerebral 
mycetism and presents a picture very closely resembling that of royxetism 
atropin poisoning, namely, dilatation of the pupils, maniacal at- 
tacks, muscular spasm and finally depression and coma. That 
cleansing of the gastro-intestinal tract by gastric lavage, emetics, 
colonic flushings and purgatives together with the administration 
of tea, coffee and tannin should be practised is self-evident. Purga- 
tion should be promoted very rapidly, however^ and for this pur- 
pose a drop of croton oil mixed with an ounce of castor oil is most 
effective. If there is much diarrhea an opiate should be adminis- 
tered. If collapse threatens, analeptics, camphor, ammonia, ether, 
black coffee. If hemoglobinuria appears common salt infusions 
should be practised directly into the veins. 



692 



THE COMMONER INTOXICATIONS 



Symptom* 
tology 



Acute poi- 
soning 



Atropine 



NITROGLYCERIN. 

An overdose of nitroglycerin causes the face to become very red ; 
there is severe headache, the pulsation of the arteries becomes clear- 
ly visible and in very severe cases there is abundant diaphoresis, 
nausea, vomiting and diarrhea, with a slow pulse, dyspnea, later 
delirium and coma. 

The treatment consists in complete cleaning out of the gastro- 
intestinal tract by gastric lavage, colonic flushings, the use of ana- 
leptics, especially of black coffee, the administration of ergot and in 
very severe cases infusion of an alkaline-saline solution directly 
into the veins (see page 671) . 

OPIUM— MORPHINE. 

In acute poisoning with or without a preliminary stage of ex- 
citement there appear dizziness, headache, tinnitus aurium, pro- 
fuse sweating, occasionally exanthematous eruptions, then relaxa- 
tion of all the muscles, somnolence and loss of consciousness, gen- 
erally associated with dryness of the mucous membrane, ischuria, 
and retardation of the pulse beat and of the respiration, the latter 
often assuming a Cheyne-Stokes type. The pupils are contracted, 
the temperature reduced. If the overdose is not fatal, the patients 
remain in deep sleep for a prolonged period of time, wake up with 
a profuse headache, nausea, vomiting, obstinate constipation. In 
fatal cases the somnolence progresses to coma with bradycardia 
and pulmonary edema; in children with convulsions, tetanus, 
opisthotonos. 

The syndrome of pin-hole pupils with cyanosis, Cheyne-Stokes 
respiration and low temperature, bradycardia and coma is usually 
diagnostic. 

The treatment consists in gastric lavage with water that is medi- 
cated with permanganate of potash in the strength of 1 : 1,000, or, 
in cases that are not unconscious, the latter solution may be admin- 
istered by mouth. Great care should be exercised in the use of 
emetics. If the permanganate solution is not at hand, tea or cof- 
fee can be used for the gastric lavage. Internally tannin should be 
given together with laxatives and colonic flushings. If the patient 
is seen before unconsciousness has occurred, a large quantity of 
black coffee should be administered and the patient forced to move 
about (ambulatory treatment) ; this should be kept up for hours at 
a time. In order to avoid heart fatigue analeptics should be given, 
the body surfaces kept warm and an ice-bag placed to the head. If 
respiratory failure threatens, artificial respiration should be prac- 
tised with rhythmic insufflation of compressed oxygen. 

The physiological antidote is atropin that should be injected 
hypodermically at once. A perfectly safe dose is 1 mg. injected 



THE COMMONER INTOXICATIONS 693 

every half hour until five or six injections have been made. The 
indication for stopping the administration of atropin is gradual 
dilatation of the pupils and an increase in the pulse rate. Nitrate 
of strychnia (2 mg.) may also be injected as an antidote until the 
breathing becomes spasmodic and twitching of the muscles is seen. 
This remedy, however, should onty be used in very extreme cases. 

Chronic opium poisoning (morphinism) manifests itself by Morphinism 
very obstinate constipation, various perversions of the appetite, a 
decrease in the excretion of saliva, an increase in the excretion of 
sweat and difficulty in urinating. The pulse is usually weak and 
slow, the skin brittle and of a dull, pale color. There is occasion- 
ally an intermittent type of fever, various ocular disturbances, 
chiefly myosis, a difference in the size of the pupils, disturbances 
of accommodation about the muscular apparatus. There is tremor, 
ataxia and great muscular weakness. The patients are very ner- 
vous, lack activity, their intelligence and memory become dull. 
There are usually insomnia and perversion of the moral sense and 
various psychoses'. 

The treatment should be carried out in an institution under 
careful guidance. The method of giving occasional doses of opium, 
codeine and bromide must be carried out very carefully. An abund- 
ance of alkaline water should be administered and the symptoms 
that result from the withdrawal of the drug treated symptomatical- 
ly. Various hypnotics and hydro therapeutic measures are here in- 
dicated. The educational side of the treatment and attempts at 
moral suasion are as important as the purely physical means. 

OXALIC ACID. 

Following the ingestion of an overdose of oxalic acid or of Symptoma- 
oxalates the patients complain of a very acid taste and of burning tolo &y 
in the mouth and pharynx. Generally the mucous lining of the 
mouth and lips is whitish, there is difficulty in swallowing, with 
vomiting of blood and mucus and bloody diarrhea,, frequently oli- 
guria and anuria with albumin and waxy casts in the urine. Vari- 
ous psychoses, dyspnea, retardation of the respiration and various 
paresthesias followed by paresis of the extremities, trismus and 
convulsions and colicky pains in the abdomen are not uncommon. 
In pregnant women abortion may occur. 

In treating a case of oxalic acid poisoning gastric lavage and Antacids 
emetics should be used with the greatest care, preferably not at 
all. For neutralizing the drug potassium and sodium salts should 
not be used, but either magnesium in the form of milk of magnesia 
or, best of all, preparations of chalk, as precipitated chalk, etc. The 
neutralization of the oxalic acid by neutral lime preparations 
should always be the first step, after this has been accomplished, 



694 



THE COMMONER INTOXICATIONS 



gastric lavage may be instituted. If there is much anuria lime salts 
should be stopped and magnesia preparations substituted for them. 
Alkalinization is to be avoided, otherwise precipitation of abundant 
calcium oxalate crystals and mechanical occlusion of the urinary 
passages may occur. In addition to the above measures an abund- 
ance of fluid should be administered as pure water or milk. 



Prophylaxis 



Symptoma- 
tology 



Copper sul- 
phate 



OYSTER POISONING—SEE FOOD POISONING. 
PHOSPHORUS. 

Phosphorus poisoning is not as common now as formerly, since 
proper preventive measures are being employed in match factories, 
where most of the cases of this disorder used to occur. The most 
distressing symptom of the chronic form of phosphorus poisoning 
is necrosis of the jaw ("phossy jaw"), which must be treated 
surgically. The first manifestations of acute phosphorus poison- 
ing are severe abdominal pain with vomiting of material that is 
luminous in the dark and has an odor of garlic. Later there is 
vomiting of bile and ejection of bloody stools, that may also be 
luminous. At the expiration of a few days, icterus, hematemesis, 
sensitiveness over the whole abdomen develop. The icterus grad- 
ually increases^ swelling of the liver and spleen occur and profuse 
vomiting soon reduces the strength of the patient. A variety of 
nervous phenomena, pain in the limbs, a soft, small, rapid pulse 
and rapid breathing appear. The urine at this time usually be- 
comes very acid and contains albumin, leucin, tyrosin, fat globules, 
blood corpuscles and fatty and epithelial casts. Many of these 
symptoms are presumably due to phosphorus liver. Hemorrhagic 
exudates in the skin and epistaxis, hematemesis, hemoptysis, hema- 
turia and uterine hemorrhages develop. Later on tremor, convul- 
sions, and death. 

The treatment consists in the administration of copper sulphate 
as an emetic from 0.1 to 1.0 g. in watery solution. Tartar emetic 
should never be given. The stomach should be thoroughly washed 
with an 0.2 to 0.3 per cent, solution of permanganate, or a 1 to 3 
per cent, solution of peroxide of hydrogen in water. Gastric lav- 
age should be continued until the wash water no longer smells of 
phosphorus. The administration of copper sulphate should be 
continued for some time. A very convenient method of adminis- 
tering it is to prepare a 1 to 60 watery solution and to give a table- 
spoonful of this mixture every fifteen minutes. At the same time 
alkaline and mucilaginous preparations should be given, while milk 
and oily or fatty articles of food should be avoided, on account of 
the solubility of phosphorus in fat. Turpentine oil is also very 
useful, the following prescription being an appropriate one : 



THE COMMONER INTOXICATION'S 695 

01. terebinthin crud., 10.0 

Mueilag. acacise, 300.0 

Syrup aurant, 20.0 

M. Sig. A tablespoonful every half hour. 

In very extreme cases intravenous infusion of an alkaline-sa- intravenous 
line solution containing one drop of turpentine oil to every 100 cc. treatment 
may be practised. Irrigation of the lower bowel with a 0.1 per 
cent, potassium permanganate solution should be frequently em- 
ployed. At the same time a purgative should be given, but not 
castor oil. The collapse and cardiac weakness should be treated 
with analeptics. 

PILOCARPIN. 

An overdose of pilocarpin produces excessive salivation, sweat- 
ing and lacrimation with nausea, vomiting and diarrhea, contrac- 
tion of the pupils and visual abnormalities, arythmia, palpitation, 
tenesmus about the bladder, headache, dizziness. The treatment 
consists in the injection of atropin until dilatation of the pupils 
occurs and removal of the drug, if it has been swallowed, by gastric 
lavage. In addition analeptics should be given. 

PRUSSIC ACID (CYANIDES, HYDROCYANIC ACID). 

The main symptoms are the characteristic odor of prussic acid, Symptoma- 
dizziness, headache, palpitation, dyspnea, very slow respiration, tolo s v 
gradual loss of consciousness, clonic and tonic spasms, finally ces- 
sation of breathing and of the heart beat. In very acute cases 
sudden collapse with arrest of breathing and very marked dilatation 
of the pupils. 

The treatment consists in immediate gastric lavage with a 0.3 Potassium per- 
per cent, solution of permanganate of potash in distilled water. If man S anate 
no stomach tube is immediately available, vomiting should be 
promptly induced by tickling the palate and by the hypodermic 
use of apomorphine. Sodium thiosulphate (natr. subsulfurosum) 
in the dose of 1 g. should be injected three or four times hypo- 
dermically or once even intravenously. The patient should be 
placed in a warm bath with cold applications to the head and arti- 
ficial respiration, preferably with oxygen, should be undertaken. 
If the convulsions are very severe, subcutaneous injections of mor- 
phine, atropin or scopolamin. Venesection is also useful, followed 
by the infusion of an alkaline-saline solution as described above 
(see page 671). If the cyanide poisoning is due to swallowing of 
bitter almonds or other plants containing amygdalin, dilute hydro- 
chloric acid or lactic acid should be administered. 



696 



THE COMMONER INTOXICATIONS 



Symptoma- 
tology 



QUININE. 

In mild cases of quinine intoxication there is a feeling of full- 
ness in the head, tinnitus and deafness, occasionally photophobia, 
amblyopia and dizziness. If a very large overdose is taken the 
temperature becomes lowered, the patients become very pale, suffer 
from abdominal pain, nausea and vomiting, while ocular and aural 
disturbances appear in a most aggravated form. Exanthemata and 
swelling of the mucous membranes of the mouth and pharynx, ic- 
terus, bloody diarrhea and methemoglobinuria (black water fever) 
are common. In pregnant women abortion is apt to occur. Twitch- 
ing of the face and extremities, cyanosis and collapse from cardiac 
weakness are usual symptoms. 

The treatment consists in elimination of the drug from the 
gastro-intestinal tract by gastric lavage, emetics, colonic flushings 
and purgatives. Tannin should be administered internally. In 
case of collapse the ordinary analeptics should be employed. 



Symptoma- 
tology 



SALICYLIC ACID AND SALICYLATES. 

An overdose of salicylic acid or salicylates produces profound 
dyspnea, stertorous breathing, severe headache with hallucinations 
and maniacal attacks, visual disturbances followed later by somno- 
lence, occasionally convulsions and coma. In addition, there are 
symptoms of local irritation about the mouth, pharynx, the stom- 
ach and the intestine. 

The treatment, in view of the rapid elimination of the drug, 
need not be very active and is largely symptomatic in character. 
Alkali carbonates, ^specially bicarbonate of soda, should be given 
in dilute watery solution in large quantities and diaphoresis stim- 
ulated by the use of pilocarpin and abundant hot water. If large 
quantities of salicylic acid or its preparations have been swallowed 
then gastric lavage should be practised. Collapse and dyspnea 
should be treated by analeptics and respiratory stimulants. 



Symptoma- 
tology 



SILVER AND SILVER SALTS. 

If the silver preparation is swallowed local evidence of irrita- 
tion of the buccal mucosa will be seen. Similar irritative phe- 
nomena appear about the stomach and intestine producing gastro- 
enteritis, pain in the abdomen, and the vomiting of whitish mate- 
rial that turns black when exposed to light. There is usually con- 
siderable dizziness followed in extreme cases by convulsions and 
paralytic symptoms about the extremities. In extreme cases death 
occurs from suffocation or pulmonary edema. 

The treatment consists in the rapid removal of the swallowed 
poison from the gastro-intestinal tract. A large proportion of the 
silver will generally be removed by spontaneous vomiting. Other- 



THE COMMONER INTOXICATIONS 697 

wise apomorphine should be administered hypodermically and gas- 
tric lavage practised with a dilute sodium chloride solution. Al- 
bumin water and milk should be administered in abundant quanti- 
ties. 

SNAKE POISONING. 

The symptoms of snake poisoning vary, of course, according to Varieties 
the species of snake that has inflicted the injury. The venoms 
of different snakes vary both in the degree and kind of toxic prop- 
erties. The most dangerous constituents are those which attack 
the nervous system (neurotoxins), the blood corpuscles (hemoly- 
sins, hemagglutinins), and the endothelium of the blood vessels 
(hemorrhagin, an endotheliotoxin). 

The main symptoms of snake bite consequently consist, aside General symp- 
from the local edema and redness at the site of the bite, with the tomat °l°gy 
accompanying lymphangitis and pain, in a variety of nervous phe- 
nomena, multiple hemorrhages, delirium, convulsions, collapse, low- 
ering of the temperature, cardiac and respiratory weakness, oc- 
casional thrombotic phenomena and sepsis. As a rule the symp- 
toms are fulminating, although occasionally an incubation period 
intervenes. 

The treatment consists in thorough excision of the wound, am- Treatment of 
putation of a finger or toe that has been bitten and the application the wound 
of a tight ligature above the point of entry of the poison, and 
otherwise of surgical procedures that can be employed to cause thor- 
ough cleansing of the infected area. Cauterization and the injec- 
tion of a 3 per cent, potassium permanganate solution into the 
wound or into the immediate neighborhood of the wound are es- 
sential measures. Internally a great abundance of alcohol should 
be given in any form. In addition analeptics like ether ? camphor 
hypodermically, active irritation of the body surfaces, stimulation 
of diuresis and diaphoresis. 

If promptly available Calmette's serum may be employed. This Calmette's 
serum or antivenin is secured by immunizing horses with a mix- serum 
ture of venoms (80 per cent, cobra and 20 per cent, viperine 
venom) well attenuated before the injections. Many months are 
required for the complete immunization of the animal. Its main 
activity is expended in the direction of neutralizing neurotoxic and 
hemolytic venoms. In the case of rattle snake poison, whose main 
toxin is hemorrhagin, it exercises little effect. 

An antivenin for rattle snake and water moccasin poisoning Antivenin 
has been prepared by immunizing horses with these venoms after 
they have been attenuated by weak acids. The serum of Noguchi is 
particularly promising. An antivenin in order to be effective should 
be administered within the first few hours after the snake bite has 



698 



THE COMMONER INTOXICATIONS 



been sustained. This is explained by the fact that snake venom 
almost immediately begins its activities without any preceding 
period of incubation. 



Symptoma- 
tology 



Tetanic attacks 



STROP HA NTH US— SEE DIGITALIS. 
STRYCHNIA (NUX VOMICA). 

The symptoms of strychnia poisoning are in mild cases dysen- 
tery, muscular rigidity and tonic spasms. In more severe cases 
trismus, tonic muscle contractions, occasionally opisthotonos oc- 
curring either spontaneously or as the result of an exaggerated re- 
sponse to a gentle stimulus. In view of the frequent involvement 
of the thoracic muscles respiratory movements are temporarily ar- 
rested, leading to a profound dyspnea. During these attacks there 
is cyanosis, the pupils are usually dilated, there is a feeling of fear 
and restlessness and the muscles are very painful between the at- 
tacks. In the beginning the pulse is slow and the arterial tension 
high. Later the pulse becomes accelerated. The patients usually 
survive two or three of the spasmodic attacks. The fourth or fifth 
one, however, is generally fatal. The treatment consists in the ad- 
ministration of emetics, preferably apomorphine administered hy- 
podermically. Gastric lavage is usually contra-indicated, on ac- 
count of the tendency of the passage of the stomach tube to induce 
one of the tetanic attacks. Tannin and LugoFs solution should 
be given. Mucilaginous fluids should be administered by mouth. 

The tetanic attacks should be suppressed by large doses of 
chloral hydrate given hypodermically or per rectum, in the begin- 
ning, in doses of from 15 to 30 or even more grains by the latter 
route. Later a similar dose may be given internally by mouth. 
For hypodermic use one or two hypodermics full of a mixture of 
equal parts of chloral hydrate and water may be administered. 
Morphine should never be given for the purpose of controlling 
the tetanic attacks. In order to stop the tetanic attacks still more 
quickly chloroform inhalation may be employed in combination 
with the administration of chloral as described above. The sur- 
roundings of the patient should be kept as quiet as possible. All 
sudden noises, strong light, all shocks or mechanical irritation 
should be avoided. Artificial respiration and rhythmic insufflla- 
tion of pure oxygen should be practised whenever possible. In case 
chloroform and chloral cannot be promptly secured then the pa- 
tient should be made drunk with abundant whisky or brandy until 
he is fast asleep. If sleep can be produced with sufficient rapidity 
then the stomach tube may safely be introduced and the stomach 
washed out with a dilute soda solution. 



THE COMMONER INTOXICATIONS 699 

SUN STROKE AND HEAT PROSTRATION. 

Exposure to high degrees of temperature produces two distinct Heat exhaus- 
disease pictures,, the one heat exhaustion, the other sun stroke or tIon 
thermic fever. The treatment of the two differs radically. 

Heat exhaustion is usually less severe in its manifestations than sun stroke 
sun stroke, although it occasionally produces death. It usually oc- Heat fever 
curs among artisans exposed to strenuous occupations in a very 
hot, confined space, such as stokers, bakers, foundrymen. The 
symptoms are all attributable to vasomotor paralysis. In the be- 
ginning there is a throbbing headache with dizziness and nausea 
and occasionally diarrhea. The skin soon becomes cold and pale, 
and covered with clammy perspiration. The patient feels very much 
prostrated and may become unconscious. The pulse is weak and 
the temperature usually subnormal. 

The patient should be immediately removed to a cooler place. 
Hot applications should be placed all about him, with cold appli- 
cations to the head. If respiration is impaired a one-hundredth of 
a grain of atropin sulphate in combination with a thirtieth of a 
grain of strychnia sulphate should be given. If the patient can 
swallow, he should be given whisky and plenty of water. Complete 
rest in bed should be enforced and all the above measures continued 
until the body surfaces again become warm, the circulation resumes 
its normal course and consciousness is restored. 

A patient suffering from sun stroke or heat fever will present 
an altogether different picture. The skin will be dry and hot. The 
face red with distended veins and throbbing arteries. There is 
stertorous breathing, a full and rapid pulse, a temperature ele- 
vated up to 105 or above. The pupils at first dilated, later some- 
times contracted, and the patient as a rule in an unconscious con- 
dition. Quite often these symptoms appear with great rapidity and 
without warning. 

The patient should at once be removed to a cool place and his Hydrotherapy 
clothing removed; he should promptly be immersed in a bath of 
80 to 85° F. that is gradually cooled. While in the water the 
body surfaces should be energetically rubbed in order to bring the 
overheated blood to the surface, where it can be cooled. The re- 
duction of the temperature should not be allowed to proceed be- 
low 102 (per rectum), as otherwise a too rapid fall of the tem- 
perature to below subnormal may occur. The bath should not be 
continued too long, as otherwise collapse may occur. Thirty min- 
utes is probably the maximum time for immersion in cool water. 
Should the temperature again rise, the bath may be repeated after 
a lapse of several hours. 

In case a bath is not accessible, the patient should be sponged 
with cold water or wrapped in a sheet wrung out of cold water. 



700 



THE COMMONER INTOXICATIONS 



This should be frequently repeated and the water gradually cooled 
to an icy temperature. The use of antipyretic drugs for the pur- 
pose of reducing the fever is a precarious procedure and should 
only be adopted if the safer water treatments cannot be carried 
out. 

Strychnia H the pulse becomes very weak after the drop in the tempera- 

ture, the patient should be given whisky by mouth, if he can swal- 
loWj otherwise a hypodermic of one-thirtieth of a grain of strych- 

Venesection nia sulphate. Venesection followed by the injection of a physio- 

logic salt solution is occasionally advisable, especially if evidence 
of congestion of the internal viscera is apparent and the action of 
the heart is very much embarrassed. 

Prophylaxis After recovery from the immediate effects of a sun stroke the 

patient should be kept very quiet for a prolonged period and until 
the pulse has been normal for at least two or three days. Any in- 
dividual who has suffered from heat prostration or a sun stroke 
should for the rest of his life be very careful to avoid exposure to 
excessive degrees of heat or to direct insolation. 



CLINICAL INDEX 



Achylia Gastrica, Gastric Hyposecre- 
tion, 555, 558 

Diet in, 556 

Enzymes in, 558 

Hydrochloric acid in, 556, 558 

Mineral waters in, 557 

Pancreas in, 556 

Sodium bicarbonate in, 558 
Acute Articular Rheumatism, Rheumatic 
Fever, 60, 66, 240 

Alcohol dressings in, 63 

Alkalies in, 62 

Antipyrin in, 62 

Aspirin in, 61, 62 

Clothing in, 64 

Cold in, 63 

Collargol in, 62 

Colchicum in, 62 

Diet in, 64 

Guaiac in, 62 

Heat in, 63 

Hot air in, 63 

Hydrotherapy of, 63 

Hygiene in, 64 

Ice-bag in, 64 

Lactophenin in, 62 

Malakin in, 62 

Oil of wintergreen in, 62, 63 

Phenacetin in, 62 

Potassium iodide in, 62 

Rest in, 64 

Salicin in, 62 

Salicylic acid in, 60 

Salicylic ointment in, 63 

Salicylates in, 60, 63 

Salicylate intoxication in, 62 

Salicylate of soda in, 61 

Saliphen in, 62 

Salipyrin in, 62 

Salol in, 62 

Sodium bicarbonate in, 63 

Sodium salicylate in, 64 

Thermophore in, 63 
Acute Tracheobronchitis, see Bronch- 
itis, 453, 461 
Addison's Disease, 340, 341 

Adrenalin in, 340 

Suprarenal extract in, 340 

Suprarenal gland in, 340 
Anemias, The — Classification of — Primary 
progressive — Progressive pernicious — 
Secondary, see Simple Anemia — Sim- 
ple—Splenic, 151-176 
Progressive Pernicious Anemia — 
Achlorhydria in, 153 



Achylia gastrica in, 152 

Arseniated mineral waters in, 156 

Arsenic in, 155 

Asiatic pill in, 157 

Causal treatment of, 151 

Cholesterin in, 157 

Defibrinated blood in, 158 

Diet in, 157 

Dried blood in, 157 

Fowler's solution in, 156 

Guberquelle water in, 156 

Hemoglobin in, 157 

Hydrochloric acid in, 154 

Hydrotherapy of, 155 

Hypochlorhydria in, 153 

Hypodermocylsis in, 158 

Iron in, 157 

Lithico water in, 156 

Normal salt solution in, 158 

Pancreas alkali in, 154 

Predigested clysmata in, 154 

Quinine in, 152 

Rectal feeding in, 154 

Rocegno water in, 156 

Sodium cacodylate in, 156 

Symptomatic treatment of, 159 

Thyroid in, 157 

Transfusion, technique of, 157 

Transfusion, indirect method of, 158 
Simple Anemia, 161-165 

Atoxyl in, 164 

Altitude in, 163 

Arsenic in, 164 

Bathing, in, 163 

Climate in, 163 

Clothing in, 163 

Diet in, 161 

Footwear in, 163 

Fowler's solution in, 164 

Iron in, 164 

Rectal feeding in, 162 

Rest in, 162 

Sodium cacodylate in, 164 
Aneurism of the Aorta, 312-317 

Acupuncture in, 315 

Cocaine muriate in, 317 

Compression in, 316 

Diet in, 312 

Diet, Tufnell, in, 313 

Filipuncture in, 315 

Galvanopuncture in, 315 

Gelatin in, 314 

Iodides in, 314 

Leiter coil in, 316 

Ligation of carotid, 316 

Ligation of subclavian artery, 316 

Liquids in, 313 



704 



CLINICAL INDEX 



Massage in, 313 

Rest in, 312 

Restriction of liquids in, 313 

Surgery in, 315 

Tufnell diet in, 313 

Venesection in, 317 
Angina Pectoris, 317-321 

Amyl nitrite in, 319 

Chloroform in, 320 

Diet in, 318 

Digitalis in, 319 

Erythrol tetranitrate in, 321 

Morphine in, 319 

Nitrites in, 319-321 

Nitroglycerin in, 320 

Potassium iodide in, 321 

Prophylaxis in, 318 
Pseudo-Angina Pectoris, 321 

Theobromin in, 319 

Theocin in, 320 
Anthrax, 109 

Immune serum in, 109 

Prophylaxis in, 109 

Serum therapy in, 109 
Appendicitis, Peritonitis, Acute, Circum- 
scribed, Perityphlitis, 634-644 
Appendicitis — 

After treatment of, 642 

Adhesions in, 643 

Blistering in, 641 

Colonic flushings in, 642 

Diet in, 639, 642 

Enemata, nutritive, in, 639 

Exercise in, 642 

Interval operation in, 642 

Interval operation, indications for, 643 

Hydrotherapy of, 642 

Leiter coil in, 641 

Massage in, 642 

Morphine in, 640 

Nutritive enemata in, 639 

Opium in, 639 

Perityphlitis, 635 
Morphine in, 640 
Priessnitz compress in, 641 

Reflex irritation in, 643 
Rest in, 638 
Surgery in, 034 
Arterio-sclerosis — Syphilitic, 309-312 

Alkalies in, 310 

Altitude in, 310 

Amyl nitrite in, 311 

Anti-sclerosin in, 312 

Bathing in, 310 

Calcium salts, reduction of, 309 

Climate in, 310 

Diet in, 309 

Diet, salt-free, in, 311 

Digitalis in, 312 

Iodopin in, 311 

Lactic acid in, 309 

Nitrites in, 311 

Nitroglycerin in, 311 

Potassium iodide in, 310 

Restriction of liquids in, 310 



Salt-free diet in, 311 

Sodium iodide in, 310 

Theocin in, 311 

Trunczek's serum in, 312 

Venesection in, 311 
Asthma. Bronchial — Cardiac — Lead — Renal 
— Uremic, 461-466 

Ammonia vapors in, 465 

Arsenic in, 463 

Belladonna in, 465 

Breathing plan in, 466 

Bromides in, 464 

Caffein in, 464 

Cannabis indica in, 465 

Chloralamid in, 464 

Cigarettes, asthma, 465 

Climate in, 463 

Cocaine in, 464 

Diet in, 462 

Digitalis in, 464 

Exercise in, 466 

Hyoscyamus in, 465 

Morphine in, 464 

Points, asthma, 462 

Potassium nitrate in, 465 

Psychotherapy of, 465 

Potassium iodide in, 46o i 

Steam atomizer in, 459 

Stramonium in, 465 

Suggestive treatment of, 462 

Tobacco in, 465 
Atrophic Cirrhosis of the Liver, see Cir- 
rhosis of the Liver, 652-661 

B 

Bartholinitis, Gonorrhoeal, 407-408 

Surgery in, 408 
Basedow's Disease, see Graves' Dis- 
ease, 334-339 
Biliary Cirrhosis of the Liver, see Cir- 
rhosis of the Liver, 652-661 
Bright's Disease, 350-369 

Altitude in, 368 

Bile acids in, 353 

Climate in, 368 

Dechloridization in, 360-362 

Diet in, 354-362 

Drinking days in, 356 

Exercise in, 369 

Hydrotherapy of, 363-368 

Indican in, 353 

Intesinal antiseptics in, 352 

Lime water in, 356 

Liquids in, 356 

Massage in, 369 

Meats, light and dark, in, 358 

Milk diet in, 354 

Mineral waters in, 356 

Organic peroxides as intestinal antisep- 
tics in, 358 

Pancreas in, 357 

Salt-free diet in, 360-362 

Sodium glycocholate in, 353 

Surgery in, 369 

Zinc sulphocarbolate as an intesinal an- 
tiseptic in, 353 



CLINICAL INDEX 



'05 



Bronchial Asthma, 461-466 
Bronchitis — Acute — Tracheo — Capillary — 
Chronic — Fibrinous — Profunda — Pu- 
trid, 453-470 
Acute Bronchitis — 

Abortion of, 453 

Aconite in, 469 

Alkalies in, 454 

Alkaline waters in, 455, 458 

Ammonium chloride in, 455, 458, 469 

Analeptics in, 470 

Apomorphine in, 456, 458, 469 

Atropine in, 455, 457, 460 

Balsams in, 456, 458 

Belladonna in, 454 

Benzoin in, 456 

Bronchitis tent, 454 

Calomel in, 469 

Camphor in, 455 

Carbolic acid in, 459 

Cascara in, 469 

Castor oil in, 469 

Climate in, 457 

Cocaine in, 462 

Codeine in, 454, 469 

Cold compresses in, 455 

Copaiba in, 456, 458 

Cough drops in, 457 

Cough syrups in, 457 

Counter irritation in, 455 

Creosote in. 459 

Cubebs in, 456, 458 

Diet in, 468 

Digitalis in, 469 

Dionin in, 454 

Dover's powder in, 454, 456, 469 

Emetics in, 455 

Eucalyptus in, 459 

Guaiacol in, 459 

Heroin in, 454 

Histosan in, 459 

Hydrotherapy of, 458, 466 

Hyoscyamus in, 454, 458 

Innalations m, 460 

Iodine in, 455 

Ipecac in, 454, 458, 469 

Licorice mixture in, 457 

Lime waters in, 459 

Magnesium sulphate in, 469 

Mist, glycerrhizse compound in, 455 

Morphine in, 454, 457 

Mustard plasters in, 455 

Narcotics in, 460, 469 

Opium in, 457 

Oxygen in, 470 

Peronin in, 454 

Potassium acetate in, 454 

Potassium carbonate in, 454 

Potassium citrate in, 454 

Potassium iodide in, 459 

Prophylaxis of, 453 

Saline waters in, 455, 458 

Santal oil in, 456, 458 

Seashore in, 458 

Senega in, 457, 469 

Sodium benzoate in, 456, 458 



Sodium bicarbonate in, 454 

Sodium carbonate in, 454 

Sodium citrate in, 454 

Steam atomizer in, 459 

Stramonium in, 454, 458 

Strophanthus in, 469 

Strychnine in, 456, 460, 469, 470 

Sulphur waters in, 458, 459 

Tartar emetic in, 456, 458, 469 

Terpene hydrate in, 456 

Terpinol in, 456 

Thiocol in, 459 

Thymol in, 459 

Tolu in, 458 

Turkish baths in, 453 

Turpentine in, 456, 458, 459 

Whisky in, 453 

X-ray in, 460 
Bronchiectasis, 460-461 

Narcotics in, 460 

Surgery in, 461 
Broncho-Pneumonia (Capillary Bronchi- 
tis), 466-470 

Aconite in, 469 

Ammonium chloride in, 469 

Analeptics in, 470 

Apomorphine in, 469 

Calomel in, 469 

Cascara in, 46a 

Castor oil in, 469 

Catharsis in, 469 

Codeine in, 469 

Diet in, 468 

Digitalis in, 469 

Dover's powder in, 469 

Hydrotherapy of, 466 

Ipecac in, 469 

Magnesium sulphate in, 469 

Morphine in, 469 

Narcotics in, 469 

Oxygen in, 470 

Senega in, 469 

Strophanthus in, 469 

Strychnia in, 469, 470 

Tartar emetic in, 469 
C 
Carcinoma of the Stomach, 533-539 

Adrenalin chloride in hematemesis, 538 

Diet in, 535 

Digestive ferments in, 536 

Gastroenterostomy in, 534 

Gastrostomy in, 534 

Hydrochloric acid in, 536 

Lavage in, 537, 538 

Lead acetate in, 532 

Resection of pylorus in, 534 

Surgery in, 533-535 
Cardiac Edema, see Cardiac Dropsy, 297-303 
Cholangitis, 668, 669 

Bile acids in, 668 

Cholagogues in, 668 

Diet in, 669 

Menthol in, 668 

Sodium benzoate in, 668 
Sodium salicylate in, 668 
Surgery in, 669 



706 



CLINICAL INDEX 



Cardiac Dropsy, 297-303 

Caffein in, 298 

Calomel in, 299 

Calomel as a diuretic in, 299 

Castor oil in, 300 

Catharsis in, 299 

Diaphoresis in, 297 

Diet, milk, in, 299 

Diet, milk, in renal congestion, 297 

Digitalis in, 298 

Diuresis in, 29s 

Diuretin in, 298 

Diuretic teas in, 299 

Epsom salts in, 299 

Glauber salts in, 299 

Jaborandi in, 297 

Magnesium sulphate in, 299 

Pilocarpine in, 297 

Potassium tartrate in, 299 

Rochelle salts in, 299 

Saline cathartics in, 299 

Sodium salicylate in, 298 

Sodium sulphate in, 299 

Sodium tartrate in, 299 

Sugar of milk, as a diuretic, in, 299 

Sweating in, 298 

Theobromin in, 298 

Tonics in, 297 
Chlorosis, 165-172 

Aloes and iron pill in, 169 

Arsacetin in, 171 

Arsenic in. 171 

Blaud's pills in, 169 

Bleeding in, 172 

Carniferrin in, 170 

Causal treatment of, 166 

Cocaine in, 170 

Diet in, 167 

Ferratin in, 170 

Ferrum cacodylicum in, 171 

Gastralgia in, 170 

Hemoglobin in, 170 

Hydrochloric acid in, 167 

Hydrotherapy of, 166 

Iron in, 167, 170 

Iron albuminate in, 170 

Iron and- aloes pill in, 169 

Iron citrate in, 170 

Iron, organic compounds of, in, 169 

Iron peptonate in, 170 

Iron perchloride in, 169 

Iron, reduced, in, 169 

Iron sulphate in, 169 

Iron waters in, 171 

Lecithin in, 171 

Manganese in, 170 

Massage in, 167 

Menthol in, 170 

Neocithin in, 171 

Neurosal element in, 166 

Rest in, 166 

Sarcinic acid in, 170 

Silver nitrate in, 170 

Sweating in, 172 

Symptomatic treatment of, 166 
Cholelithiasis, 661-668 

Cholagogues in, 663 



Clothing in, 663 

Diet in, 662 

Exercise in, 663 

Glycerin in, 664 

Massage in, 663 

Mineral waters in, 662 

Olive oil in, 664 

Prophylaxis of, 661 

Surgery in, 665-666 
Colic, Gall Stone, 667 

Belladonna in, 667 

Castor oil in, 668 

Chloral in, 667 

Chloroform in, 667 

Hydrotherapy of, 667 

Morphine in, 668 

Oil enemas in, 668 

Opium in, 667 

Salicylates in, 667 
Cholecystitis, 668, 669 

Diet in, 669 
Cholera, 105, 106 

Antibacteria serums in, 20 

Inoculation, protective, in, 18 

Isolation in, 105 

Prophylaxis in, 105 

Vaccination in, 106 
Capillary Bronchitis, Broncho-Pneu- 
monia 466-470 
Chronic Rheumatism, see Rheumatism, 

239-243 
Cirrhosis of the Liver — Atrophic — Biliary 
— Cardiac — Hypertrophic — Pericarditic 
Pseudo, 652-661 

Alkalies in, 660 

Antipyrin in, 660 

Cholagogues in, 660 

Diet in, 657-659 

Exercise in, 659 

Hydrotherapy of, 659 

Intestinal antisepsis in, 657 

Oxidizing treatment in, 659 

Organotherapy of, 660 

Salicylates in, 660 

Surgery in, 660, 661 

Urea in, 660 
Cretinism, see Myxedema, 331-334 
Chronic Aortitis, see Arterio-sclerosis, 309- 

312 
Constipation — Alimentary — Atonic — 
Chronic — Habitual — Physiological — 
Spastic, 603-616 

Aloes in, 612, 614 

Aloin in, 616 

Anthracene purgatives in, 612 

Apenta water in, 615 

Apentol in, 614 

Aperient cathartic in, 612 

Apocodeine in, 616 

Blue pill in, 613 

Calomel in, 613 

Cascara in, 612 

Castor oil in. 610, 612 

Cathartic, aperient, in, 612 

Cathartic, hydragogue, in, 612 



CLINICAL INDEX 



707 



Cathartic, saline, in, 612 

Cathartinic acid in, 616 

Citrullin in, 616 

Colocynth in, 612, 616 

Croton oil in, 612 

Douching of the abdomen in, 609 

Diet in alimentary constipation, 604 

Diet in atonic constipation, 606 

Drastic purges in, 612 

Effervescent laxative salts in, 615 

Elaterin in, 612 

Elaterium in, 614 

Electricity in, 609 

Enemata in, 610, 611 

Epsom salts in, 615 

Frangulus in, 612 

Glycerin in, 610 

Gray powder in, 613 

Hydragogue cathartic in, 612 

Hydrotherapy of, 608 

Hypodermic purgation in, 616 

Hunyadi janos in, 615 

Jalap in, 612, 614 

Laxative cathartic in, 612 

Laxatives in, 611, 612 

Laxatives, saline, in, 615 

Laxative salts, effervescent, in, 615 

Leptandra in, 612 

Magnesium sulphate in, 616 

Massage in, 607 

Oil injections in, 611 

Phenolphthalein in, 614 

Podophyllum in, 612, 614 

Priessnitz compress in, 609 

Purgatives, anthracene, in, 612 

Purgatives, vegetable, in, 612 

Purgatives, oils in, 612 

Regulin in, 615 

Rhubarb in, 612, 613 

Rochelle salts in, 615 

Saline cathartics in, 612 

Saline laxatives in, 615 

Scottish douches in, 609 

Seidlitz powder in, 615 

Senna in, 612, 613 

Sitz bath in, 608 

Smoking in, 607 

Sulphur in, 614 

Swedish movements in, 609 

Yeast in, 607 
Constipation Spastic, 605 

Belladonna in, 606 

Opium in, 606 
Coryza Vasomotoria, see Hay Fever, 442- 
444 

COWPERITIS, GONORRHOEAL, 406 

Massage in, 406 
Surgery in, 406 
Cystitis, 389-396 
Argyrol in, 393 
Balsams in, 391 
Benzoic acid in, 392 
Boric acid in, 392-394 
Buchu in, 391 
Chinosol in, 394 
Calomel in, 390 



Camphoric acid in, 392 

Collargol in, 394 

Diet in, 390 

Gomenol in, 393 

Gonosan in, 391 

Guaiacol in, 393 

Herniaria in, 391 

Hexamethylentetramine (see Urotropin) 

Iodoform in, 393 

Jalap in, 390 

Lead acetate in, 394 

Magnesium citrate in, 390 

Mercury bichloride in, 393 

Nitric acid in, 393 

Pichi in, 391 

Prophylaxis of 389, 390 

Pyoktanin in, 394 

Salicylic acid in, 394 

Salol in, 390 

Santal oil in, 391 

Santyl in, 391 

Silver nitrate in, 393 

Urotropin in, 392 

Uva Ursi in, 390 

D 

Diabetes Mellitus, 271-272 
Alcohol in, 216 
Aleuronat bread in, 200 
Alkalies in, 213 
Antipyrin in, 222 
Arsenic in, 215 
Aspirin in, 213 
Atropine in, 210, 212 
Belladonna in, 212 
Beta-naphthol in, 218 
Bismuth subnitrate in, 220 
Bleeding in, 219 

Boundary of assimilation in, 195 
Breads in, 200 
Bromides in, 212 
Calcium carbonate in, 214, 221 
Calorimetric methods in, 193 
Carlsbad in, 214 
Cerium oxalate in, 220 
Chewing in, 210 
Chloral in, 212 
Cholorform water in, 220 
Cocaine in, 219 
Codeine in, 212 
Coma in, 214, 222. 
Creosote in, 215 
Crystallose in, 216 

Equivalents of white bread, 200, 201 
Eucaine ointment in, 219 
Exercise in, 217 
Fetor in, 218 
Gluten bread in, 200 
Iron in, 215 
Jambul in, 215 
Lactic acid in, 215 
Levulose in, 216-222 
Liver extracts in, 216 
Massage in, 218 
Mercury bichloride in, 215 
Milk cure in, 203 



708 



CLINICAL INDEX 



Mineral waters in, 214 

Morphine in, 212 

Naunyn in, 200 

Oatmeal cure in, 203 

Opiates in, 212, 220, 222 

Organotherapy in, 215 

Orthorform in pruritus, 219 

Ox-gall in steatorrhea, 221 

Pancreas in, 330 

Pancreas powders in, 206 

Pancreas preparations in, 215 

Pancreatin in steatorrhea, 221 

Phenacetin in, 212 

Phenol in, 215 

Plasmon bread in, 200 

Potassium iodide in, 214, 215 

Potato cure in, 203 

Quinine in, 214, 222 

Rhubarb in, 221 

Rice cure in, 203 

Roborat bread in, 200 

Saccharine in, 216 

Salicylic acid in, 212 

Salivary gland extract in, 215 

Senna in, 221 

Smoking in, 210 

Sodium bicarbonate in, 206, 223 

Sodium carbonate in, 221 

Sodium glycocholate in, 206 

Sodium salicylate in, 212, 219 

Starvation plan in, 200 

Sugar substitutes in, 216 

Sulfopyrin in, 215 

Sulphonal in, 212 

Suppositories, tannic acid, in, 220 

Tannic acid suppositories in, 220 

Test meal in, 195, 197 

Valerian in, 212 

Vicarious feeding in, 193 

Vichy in, 214 

Yeast in, 216, 219 
Diabetes Insipidus, 271-272 

Antipyrin in, 271 

Asafetida in, 271 

Camphor in, 271 

Ergot in, 272 

Galvanization in, 272 

Hydrotherapy of, 271 

Hypnotism in, 271 

Liquids, reduction of, in, 272 

Potash in, 271 

Potassium bromide in, 271 

Reduction of liquids in, 272 

Sweating in, 272 

Valerian in, 271 
Diarrhoea — Dyspeptica — Gastrica — Nerv- 
ous — Vasomotoria, 616-621 

Almatein in, 619 

Bismuth in, 619 

Calomel in, 616 

Castor oil in, 616 

Diet in, 616, 618 

Diet, prophylactic, in, 616 

Lead acetate in, 619 

Opiates in, 619 
Silver nitrate in, 619 



Tannin in, 619 
Diphtheria, 50-53 

Antipyretics in, 54 

Antitoxic serum in, 20 

Apomorphine in, 55 

Boric acid solution in, 53 

Carbolic acid in, 53 

Cold in, 53 

Creolin in, 53 

Diet in, 54 

Emetics in, 55 

Ferric chloride in, 53 

Hydrogen peroxide in, 53 

Hydrotherapy of, 54 

Intubation in, 55 

Iodoform in, 53 

Ipecac in, 55 

Lactic acid in, 53 

Local treatment in, 52 

Loeffler's solution in, 53 

Mercury inunction in, 54 

Potassium chlorate in, 53 

Pilocarpine in, 55 

Rest in, 54 

Salicylic acid solution in, 53 

Serum therapy of, 50 

Silver inunction in, 54 

Silver nitrate in, 53 

Sodium bicarbonate in, 53 

Tartar emetic in, 55 

Tracheotomy in, 55 

Unguentum crede in, 54 

Unguentum hydrargyri in, 54 
Dysentery — Catarrhal — Chronic — End- 
emic — Sporadic — Symptomatic, 69-72 

Antibacterial serums in, 20 

Calomel in, 70 

Castor oil in, 70 

Cocaine in, 71 

Diet in. 70 

Enterocylsis in, 70 

Ice water in, 71 

Iodoform in, 71 

Ipecac in, 70 

Iron perchloride in, 71 

Laxatives in, 70 

Laudanum-starch enemata in, 71 

Morphine in, 71 

Narcotics in, 71 

Naphthalin in, 70 

Olive oil in, 70 

Opium in, 71 

Quinine in, 71 

Silver nitrate in, 71 

Sodium sulphate in. 71 

Tannalbin in, 70, 72 

Tannin in, 71 

E 

Endocarditis — Acute — Septic — Syphilitic 
— Ulcerative, 304-306 
Aconite in, 306 
Ammonium chloride in, 306 
Carbolic acid in, 305 
Digitalis in, 306 
Mercury bichloride in, 305 



CLINICAL INDEX 



709 



Orthocresol in, 305 

Potassium iodide in, 306 

Prophylaxis of, 305 

Quinine in, 305 

Rest in, 305 

Sodium carbonate in, 306 

Sodium iodide in, 306 
Epidemic Cerebro-spinal Meningitis, 110- 
112 

Alconol in, 112 

Boracic acid in, 111 

Bromides in, 111 

Calomel in, 111 

Chloral in, 111 

Diet in, 111 

Dobell's solution in, 111 

Ergot in, 111 

Antiseptic ergot in, 111 

Hydrotherapy of, 112 

Quinine in, 112 

Lumbar puncture, technique of, 111 

Salines in, 111 

Serum treatment in, 110 

Specific treatment in, 110 

Sodium iodide in, 112 

Strychnine in, 112 

Venesection in, 112 
Epididymitis, Gonorrheal, 404-405 

Balsams in, 405 

Guaiacol in, 404 

Rest in, 404 
Epistaxis, 444-449 

Aconite in, 447 

Aloes in vicarious epistaxis, 450 

Cauterization in, 446 

Chloral in, 449 

Cimicifuga in vicarious epistaxis, 449 

Cotarnine in, 448 

Digital compression in, 447 

Digitalis in, 448 

Ergot in, 448 

Hydrastine hydrochlorid in, 448 

Hydrastis in, 448 

Ice compress in, 446 

Ice water injections in, 446 

Leeches in vicarious epistaxis, 449 

Ligating extremities in, 447 

Morphine in, 449 

Nitroglycerin in, 447 

Opium in, 449 

Plugging of nares in, 447 

Tampons in, 446 

Topical treatment of, 446 

Venesection in, 448 

Veratrum viride in, 447 
Exophthalmic Goitre, see Graves's Dis- 
ease, 334-339 

F 
Fatty Degeneration of the Heart, 303-304 

Diet in, 303 

Infiltrations in, 303 

Prophylaxis of, 303 
Fever, 22-24 

Alcohol in, 22 

Albumen in, 22 



Antipyretics in, 21 

Antipyrin in, 22 

Carbohydrates in, 22 

Curare in, 22 

Fats in, 22 

Nitrogen equilibrium in, 22 

Quinine in, 22 

Rectal feeding in, 24 

Salicylates in, 22 

Salicylic acid in, 22 

Sweating in, 21 

Temperature regulation, 21 
Floating Kidney, 381-383 

Bandaging in, 382 

Clothing in, 383 

Fattening cure in, 382 

Mast cure in, 382 

Nephrorrhaphy in, 383 

Pads in, 392 

Rest in, 382 

Surgery in, 383 
Flatulency, 621-624 

Anise seed in, 623 

Asafetida in, 623 

Caraway seed in, 623 

Cardamom in, 623 

Carbo-animalis in, 624 

Carminatives in, 623 

Charcoal in, 624 

Cinnamon in, 623 

Cloves in, 623 

Diet in, 622 

Fennel in, 623 

Ginger in, 623 

Kephyr in, 622 

Lemons in, 623 

Magnesia usta in, 624 

Nutmeg in, 623 

Orange peel in, 623 

Peppermint in, 623 

Physostigmine in, 624 

Thyme in, 623 



Gall Stones, see Cholelithiasis, 661-668 
Gastric Hyperchlorhydria — Hypersecre- 
tion, 549-555 

Alkalies in, 554 

Atropine in, 553 

Belladonna in, 553 

Boric acid in, 553 

Calcium carbonate in, 555 

Diet in, 550-52 

Douching in, 553 

Gastroplication in, 49 

Lavage in, 553 

Magnesium sulphate in, 554 

Mineral waters in, 552 

Pyloroplasty in, 549 

Resorts in, 555 

Silver nitrate in, 553 

Smoking in, 553 

Sodium bicarbonate in, 555 

Surgery in gastrectasy, 48, 549 
Gastric Ulcer, 522-533 

Adrenalin chloride in, 531 



710 



CLINICAL INDEX 



Antacids in, 527 

Atropine in, 527 

Belladonna in, 527 

Bismuth salts in, 528 

Carlsbad salts in, 527 

Choloroform in, 528 

Diet in, 523 

Ergotine in, 532 

Ewald's nutritive enema in, 525 

Ferric chloride gelatine in, 532 

Hydrastis in, 532 

Morphine in, 531 

Narcotics in, 530 

Nutritive enemas, 524, 525 

Nutritive enemas, peptones in, 525 

Olive oil in, 530 

Orthoform in, 530 

Peptones in nutritive enemas, 525 

Prophylaxis of, 522 

Rectal feedings in, 523, 524 

Rest in, 523 

Silver nitrate in, 528 

Surgery in, 533 

Witte's peptone, 525 
Gastritis, Acute, 599-510 

Alkalies in, 512. 517 

Apomorphine in, 500 

Anis in, 519 

Belladonna in, 502 

Bitter almonds in, 519 

Bromelin in, 520 

Caraway in, 519 

Calomel in, 502 

Cardamoms in, 519 

Castor oil in, 502 

Cinnamon in, 519 

Cocaine in, 502 

Condurango in, 518 

Cradin in, 520 

Cinchona in, 518 

Diastase in, 521 

Diet in, 499-506 

Digestibility of foods in, 503-510 

Digestive ferments in, 520 

Lavage in, 500 

Prophylaxis of, 510 
Gastritis, Chronic, 510-522 

Anis in, 519 

Bitter almonds in, 519 

Bromelin in, 520 

Caraway in, 519 

Cinnamon in, 519 

Digestive ferments in, 520 

Gentian in, 518 

Hydrochloric acid, use and abuse of, 
in, 515-517 

Ipecac in, 499 

Lavage in, 500, 512 

Lime water in, 514 

Mineral waters in, 512, 513 

Morphine in, 502 

Mustard in, 519 

Nutmeg in, 519 

Nux vomica in, 518 

Orexine in, 519 

Pancreatin in, 520 



Pancreon in, 521 

Papain in, 520 

Pepsin in, 520 

Potassium permanganate in, 512 

Priessnitz compress in, 502 

Prophylaxis of, 510 

Ptyalin in, 521 

Quassia in, 518 

Salicylic acid in, 512 

Smoking in, 510 

Stomachics in, 518 

Syphonage in, 501 

Taka-diastase in, 521 

Tartar emetic in, 499 

Thymol in, 512 
Gastroptosis, 600-603 

Abdominal binders in, 603 

Diet in, 603 

Electrotherapy of, 601 

Fattening cure in, 603 

Hydrotherapy of, 601 

Oil injections in, 602 

Opium in, 602 

Psychotherapy of, 601 
Gingivitis, 435, 436 
Gonorrhea, 397, 407, 429 

Alum in, 401 

Argyrol in, 401 

Astringents in, 401 

Copper sulphate in, 401 

Crurin in, 401 

Diet in, 396 

Electrolysis in, 407 

Gonosan in, 402 

Lead acetate in, 401 

Prophylaxis of, 398 

Protargol in, 400 

Rectapnore in, 403 

Resorcin in, 401 

Serum treatment in, 429 

Suspensory in, 398 

Zinc sulphate in, 401 

Zinc sulphocarbolate in, 401 
Goitre, Simple, 339 

Thyroid in, 339 

Thymus in, 339 

Thyroid therapy of, 330 
Gout, see Uric Acid Diathesis, 61 
Graves' Disease (Basedow's Disease) 334 
339 

Aconite in, 337 

Altitude in, 335 

Arsenic in, 337 

Bromides in, 337 

Camphor in, 337 

Climate in, 33b 

Digitalis in, 337 

Electricity in, 336 

Diet in. 336 

Hydrotherapy of, 337 

Hyoscine hydrobromate in, 337 

Iodine in, 338 

Iron in, 337 

Resection of the sympathetic in, 33S 

Rest in, 335 



CLINICAL INDEX 



711 



Sodium sulphate in, 337 
Surgery in, 338 
Thymus in, 335 
Thyroidectin in, 335 
Thyroidectomized animals, 335 
Thyroidectomy, 338 
Valerian in, 337 

H 

Hay Fever, Coryza Vasomotoria, 442-444 

Abortive treatment of, 443 

Adrenalin in, 443 

Ambrosia artemisi in, 443 

Antitoxic serum in, 444 

Atropine in, 443 

Belladonna in, 443 

Capsicum in, 443 

Cocaine in, 443 

Hydrotherapy of, 443 

Menthol-camphor in, 443 

Morphine in, 443 

Opium in, 443 

Pollantin in, 444 

Prophylaxis of, 443 

Salicylic acid in, 443 

Serum, antitoxic, in, 444 

Sprays in, 443 
Hemophilia, 182, 183 

Alcohol in, 182 

Calcium chloride in, 183 

Diet in, 182 

Epistaxis in, 183 

Ergot in, 183 

Gelatine in, 183 

Hydrastis in, 183 

Lead acetate in, 183 

Lemons in, 183 

Mineral acids in, 183 

Opiates in, 183 

Prophylaxis of, 182 

Sulphates in, 183 

Vaccination in, 182 
Hemoptysis, Vicarious, 483-488 

Aconite in, 485 

Cotarnine in, 487 

Diet in, 488 

Ergot in, 487 

Gelatin in, 487 

Hamamelis in, 487 

Hemostan in, 486 

Ipecac in, 484 

Lead acetate in, 487 

Ligation in, 486 

Morphine in, 485 

Opium in, 483 

Prophylaxis of, 483 

Rest in, 488 

Sodium nitrite in, 485 

Strychnine in, 486 

Tannic acid in, 487 

Turpentine in, 487 
Hemorrhagic Diathesis — Scurvy — Hemo- 
philia— Purpura, 180-185 

Adrenalin in, 181 

Catechu in, 181 

Diet in, 180 



Ergot in, 181 

Gelatine in, 181 

Herba cochleria in, 181 

Horseradish in, 181 

Hydrogen peroxide in, 181 

Iron chloride in, 181 

Iron perchloride in, 181 

Myrrh in, 181 

Potassium chloride in, 181 

Potassium salts in, 180 

Prophylaxis of, 181 

Quinine in, 181 

Rest in, 181 

Salted foods in, 180 

Silver nitrate in, 181 

Tamponade in, 181 

Tannic acid in, 181 

Yeast in, 181 
Hepatic Insufficiency, 652-661 

Chloroform in, 660 

Hepatic Hyperemia (associated with 
Heart Disease), see Valvular Disease 
of Heart 
Hookworm Disease, 628 

Betanaphthol in, 628, 630 

Compound cathartic pill in, 629 

Eucalyptus in, 628 

Male fern in, 628 

Serum therapy in, 631 

Thymol in, 628 
Hydrophobia, 104, 105 

Prophylaxis of, 104 

Vaccine in, 105 

Virus in, 104 
Hypertrophic Cirrhosis of the Liver, see 
Cirrnosis of the Liver, 652-661 



Icterus, 649-652 

Bile acids in, 651 

Calomel in, 649 

Castor oil in, 649 

Cholagogues in, 651 

Colonic flushing in, 651 

Diet in, 649 

Hydrotherapy of, 652 

Magnesium sulphate in, 649 

Mineral waters in, 650 

Purgatives in, 649 

Salicylates in, 651 

Salol in, 652 

Salines in, 649 

Sodium phosphate in, 649 
Ileus, Intestinal Stenosis and Occlusion, 
583-596 

Air inflation in, 589 

Atropine in, 592 

Axial rotation of the bowel, 584 

Diet in, 596 

Electricity in, 594 

Hypodermoclysis in, 596 

Lavage in, 587 

Laxatives in, 593 

Massage in, 594 

Mercury in, 587 

Opium in, 590, 592 < ' 



712 



CLINICAL INDUX 



Puncture of the bowel in, 595 
Oil injections in, 589 
Rectal feeding in, 596 
Salt enemata in, 589 
Surgery in, 583 

Influenza, 72, 73 
Alcohol in, 72 
Antineuralgics in, 72 
Antipyrin m, 72 
Aspirin in, 72 
Calomel in, 72 
Dover's powder in, 72 
Hydrotherapy of, 72 
Ice-bag in, 72 
Quinine in, 72 
Saline laxative in, 72 
Salipyrin in, 72 

Intestinal Catarrh, Acute, 573-577 

Aconite in, 577 

Ammonia in, 577 

Analeptics in, 577 

Antiseptics in, 576 

Benzo-naphthol in, 576 

Calomel in, 573, 576 

Camphor in, 577 

Castor oil in, 573 

Colonic flushings in, 574 

Creosote in, 576 

Dover's powders in, 577 

Diet in, 575 

Ether in, 577 

Formaldehyde in, 576 

Glutoid capsules in, 576 

Hydrochloric acid in, 576 

Ichthoform in, 576 

Ichthyol in, 576 

Keratinized pills in, 576 

Menthol in, 576 

Morphine in, 577 

Narcotics in, 577 

Opium in, 577 

Peroxides, organic, in, 576 

Resorcin in, 576 

Salicylic acid in, 576 

Sodium glycocholate in, 576 

Sulphocarbolates in, 576 

Turpentine stupes in, 577 
Intestinal Catarrh, Chronic, 578-583 

Alkaline-saline waters in, 581 

Alum in, 581 

Bismuth preparations in, 580 

Boric acid in, 582 

Carlsbad in, 581 

Castor oil in, 581 

Catechu in, 580 

Clothing in, 583 

Colombo in, 580 

Colonic flushings in, 582 

Cresoline in, 582 

Dermatol in, 580 

Diet in, 578 

Endoxin in, 580 

Exercise in, 582 

Hydrotherapy of, 582 

Kino in, 580 

Lead acetate in, 581 



Marienbad in, 581 

Mineral waters in, 581 

Opium in, 582 

Orphol in, 580 

Rest in, 582 

Rhatany in, 580 

Salicylic acid in, 58A 

Silver nitrate in, 582 

Sulpho-saline waters in, 581 

Tannalbin in, 580 

Tannic acid in, 579 

Tannigen in, 580 

Tannin in, 582 

Vichy in, 581 

Xeroform in, 580 

Yeast in, 580 

Zinc sulphate in, 581 
Intestinal Occlusion, see Ileus, 583-596 
Intestinal Ulcer, 597-600 

Adrenalin in, 599, 600 

Alum in, 600 

Bismuth in, 598, 600 

Boric acid in, 599 

Calcium chloride in, 599, 600 

Diet in, 598 

Ergot in, 599 

Gelatine in, 600 

Hamamelis in, 599 

Hydrastis in, 599 

Iron perchloride in, 600 

Lead acetate in, 600 

Mercury bicnloride in, 599 

Opium in, 598, 599 

Salicylic acid in, 599 

Silver nitrate in, 599, 600 

Tannalbin in, 599 

Tannigen in, 599 

Thymol in, 599 



Jaundice, see Icterus, 649-652 

L 
Laryngitis, 450-451 

Abortion of, 450 

Ammonium carbonate in, 450 

Calomel in, 450 

Camphor in, 450 

Cocaine in, 451 

Benzoin in, 450 

Eucalyptus in, 450 

Inhalations in, 450 

Juniper in, 450 

Magnesium sulphate in, 450 

Menthol in, 451 

Opium in, 451 

Potassium bromide in, 451 

Sodium bicarbonate in, 451 

Terebinth in, 450 



Leukemia — Leucocy tic — Lymphati 
elogenous — Splenic, 172-176 
Agaricine in, 175 
Alum in, 175 
Arsenic in, 173, 175 
Atropine in, 175 
Belladonna in, 175 
Bowel antisepsis in, 173 



— My- 



CLINICAL INDEX 



713 



Bone marrow in, 174 

Camphoric acid in, 175 

Causal treatment of, 172 

Diet in, 175 

Ergot in, 175 

Galvano puncture in, 175 

Iodides in, 174 

Iodine in, 174 

Iron in, 174 

Lymph glands, extract of, in, 174 

Oxygen in, 174 

Phosphorus in, 174 

Quinine in, 174 

Roentgen rays in, 175 

Sodium arsenate in, 174 

Sodium cacodylate in, 174 

Spleen, extract of, in, 174 

Splenectomy in, 175 

Sweating in, 175 

Tuberculin in, 174 

M 
Malaria, 55-60 

Acetanilid in, 59 

Acupuncture in, 60 

Antipyrin in, 59 

Carbolic acid in, 59 

Eucalyptus in, 59 

Euquinine in, 56 

Faradization in, 60 

Methylene blue in, 58 

Opium in, 56 

Phenacetin in, 59 

Quinine in, 55 

Quinine bimuriate in, 56 

X-ray in, 60 
Measles, 83, 84 

Apomorphine in, 83 

Bismuth subgallate in, 84 

Camphorated oil in, 84 

Diet in, 84 

Dover's powder in, 83 

Hygiene in, 83 

In pseudo-leukemia, 177 

Intubation in, 84 

Potassium bromide in, 84 

Prophylaxis of, 83 

Tracheotomy in, 84 
Membranous Enteritis, 600-603 

Diet in, 603 

Electrotherapy of, 601 

Hydrotherapy of, 601 

Oil injections in, 602 

Opium in, 602 

Psychotherapy of, 601 
Enteroptosis, 600-603 

Abdominal binders in, 603 

Diet in, 603 

Electrotherapy of, 601 

Fattening cure in, 603 

Hydrotherapy of, 601 

Oil injections in, 602 

Opium in, 602 

Psychotherapy of, 601 



Meteorism, 621-624 

Anise seed in, 623 

Asafetida in, 623 

Carbo-animalis in, 624 

Cardamom in, 623 

Carminatives in, 623 

Charcoal in, 624 

Cinnamon in, 623 

Cloves in, 623 

Colonic irrigation in, 624 

Diet in, 622 

Fennel in, 623 

Ginger in, 623 

Kephyr in, 622 

Lemon in, 623 

Magnesia usta in, 624 

Nutmeg in, 623 

Orange peel in, 623 

Peppermint in, 623 

Physostigmine in, 624 

Puncture of the bowel in, 624 

Sassafras in, 623 

Thyme in, 623 

Turpentine in, 624 

Turpentine stupes in, 624 
Motor Insufficiency of the Stomach — 
Gastric Dilatation — Gastric Ectasy — 
Gastric Atony, 540-549 

Ammonium fluorid in, 542 

Diet in gastric atony, 541, 542 

Diet in fermentative dyspepsia, 542 

Drink restriction in gastric atony, 544 

Erythrol in butyric dyspepsis, 542 

Gastrectasy, 540 

Picrotox in butyric dyspepsia, 543 

Rectal feeding in gastric atony, 544 

Tetany in gastric atony, 544 
Mucous Colic, Colica Mucosa, 600-603 

Diet in, 603 

Electrotherapy of, 601 

Hydrotherapy of, 601 

Oil injections in, 602 

Opium in, 602 

Psychotherapy of, 601 
Muscular Rheumatism, see Rheumatism, 

241 
Myocarditis — Acute — Chronic, 303, 304 

Alaklies in, 304 

Colocynth in, 300 

Croton oil in, 300 

Elaterium in, 300 

Jalap in, 300 

Podophyllum in, 300 

Prophylaxis of, 303 

Quinine in, 303 

Scarification in, 301 

Sodium salicylate in, 304 

Southey Trocars in, 301 

Surgery in, 300 
Myxedema — Fetal — Infantile — Myxede- 
matous Idiotism, 331-334 

Administration of thyroid in, 332 

Iodothyrin in. 334 

Preparations of thyroid in, 333 

Thyroiodin in, 334 



714 



CLINICAL INDEX 



N 

Nephritis — Acute — Chronic — Vascular, 343- 
369 

Alkalies in, 348 

Balsams in, 344 

Buttermilk in, 345 

Caffein in, 348 

Calomel in, 348 

Cantharides in, 344 

Caseara in, 350 

Castor oil in, 350 

Clothing in, 346 

Diet in, 345, 346 

Digitalis in, 348 

Drink restriction in, 344 

Diuretic tea in, 349 

Hydrotherapy of, 349 

Kefir in, 345 

Kidney extracts in, 330 

Kumyss in, 345 

Meat in, 346 

Milk diet in, 345 

Mineral waters in, 348 

Potassium acetate in, 348 

Potassium chlorate in, 344 

Prophylaxis or, 343 

Salicylic acid in, 344 

Salines in, 350 

Starvation in, 345 

Sweating by pilocarpine, 349 

Tar in, 344 

Turpentine in, 344 
Nephrolithiasis — Oxalurica — Phosphatica 
— Urica, 373-387 

Alkalies in, 374 

Belladonna in, 379 

Bovertin in, 378 

Calcium in, 375-377 

Chloral hydrate in, 379 

Chloroform in, 379 

Diet in, 374 

Ergot in hematuria, 379 

Ergot in, 379 

Erigeron in, 379 

Glycerin in, 378 

Hydrastis in, 379 

Hydrochloric acid in, 381 

Lithium as a uric acid solvent in, 377, 378 

Lysidin in, 378 

Mineral waters in, 377 

Muriatic acid in, 381 

Olive oil in, 379 

Opium in, 379 

Piperazin in, 378 

Phosphoric acid in, 381 

Prophylaxis of, 374 

Sidonal in, 378 

Sodium benzoate in, 378 

Surgery in, 379 

Tannigen in, 379 

Urea in, 378 

Uric acid solvents, 377 

Uro tropin in, 378 
Neuroses of the Stomach, 558-571 

Bandaging in, 546 

Boric acid in, 545 



Douching in, 546 

Electricity in, 546 

Hydrotherapy of, 547 

Lavage in, 545 

Massage in, 547 

Mineral waters in, 548 

Nux vomica in, 548 

Oil cure in, 548 

Resorcin in, 545 

Salicylic acid in, 545 

Silver nitrate in, 546 

Sodium chloride in, 546 
Neuroses, Motor, 564 

Atropine in, 566 

Atropine methyl bromate in, 570 

Belladonna in, 566 

Bromides in, 566 

Bromides in seasickness, 567 

Chloral in seasickness, 567 

Chloroform in, 570 

Chloroform in seasickness, 567 

Douching in achylia gastrica, 557 

Douching in gastric atony, 546 

Electricity in, 562 

Exercise in, 564 

Hydrotherapy of, 560-562 

Lavage in achylia gastrica, 557 

Lavage in seasickness, 567 

Morphine in, 570 

Resorts in, 561 

Massage in, 562 

Priessnitz compress in, 561 

Suggestion in, 560 

Opium in nervous vomiting, 566 

Peristaltic unrest in, 564 

Picrotoxin in, 567 

Picrotoxin in seasickness, 567 
Neuroses, Secretory, 568 

Asafetida in, 568 

Bromides in, 568 

Hydrotherapy of, 568 

Valerian in, 568, 571 
Neuroses, Sensory, 569 

Antipyrin in, 570 

Bromoform in. 570 

Cocaine in, 570 

Diet in, 570 

Electricity in, 569 

Phenacetin in, 570 

Pyramidon in, 570 

Smoking in, 571 

Starvation in, 571 

Belladonna in, 566 

Weir Mitchell Cure, 562, 570, 571 

Winternitz compress, 569 



Obesity, 225-238 
Alcohol in, 234 
Banting cure for, 231 
Bronchitis in, 226, 457 
Carbuncles in, 227 
Carlsbad in, 236 
Dietetic treatment of, 229 
Epstein cure for, 231 
Hirschfeld cure for, 231 



CLINICAL INDEX 



715 



Hydrotherapy of, 237 

Kissingen in, 236 

Marienbad in, 236 

Massage in, 237 

Mineral water in, 236 

Muscular exercise in, 237 

Nauheim in, 237 

Oertel-Terrain cure for, 231, 237 

Reduction cures, three degrees of, in 229, 

230 
Resort treatment of, 236 
Restriction of liquids in, 233 
Thyroid in, 238 
Vichy in, 236 
Osteomalacia, 270, 271 
Adrenalin in, 271 
Arsenious acid in, 270 
Atropine in, 270 
Calcium in, 270 
Codliver oil in, 270 
Diet in, 271 
Hygiene in, 271 
Phosphorus in, 270 



Palpitation, 321-325 

Aconite in, 324 

Asafetida in, 325 

Bathing in, 323 

Bornyval in, 325 

Bromides in, 324 

Chloral in, 325 

Chloroform in, 325 

Diet in. 323 

Exercise in, 323 

Faradization of the vagus in, 324 

Lavage in, 325 

Morphine in, 325 

Prophylaxis of, 323 

Rest in, 323 

Sodium bromide in, 324, 325 

Vagus, faradization of, in, 324 

Valerianates in, 324, 325 
Parotitis, 78 

Diet in, 78 

Hydrotherapy of, 78 

Hygiene in, 78 
Pericarditis, 306-308 

Analeptics in, 307 

Catharsis in, 308 

Cold in, 306 

Diet in, 307 

Digitalis in, 307 

Diuresis in, 308 

Morphine in, 306 

Paracentesis of pericardium, 308 

Pericardotomy, 308 

Priessnitz Compress in, 307 

Quinine in, 306 
Peritonitis, Acute, Circumscribed — Per- 
forative — Chronic — Diffuse — Fibro-pur- 
ulent — Tuberculous, 634-647 

Alcohol in, 634 

Analeptics in, 634 

Adrenalin in, 634 

Bandaging in, 646 



Chloroform in, 633 

Cocaine in, 633 

Compresses in, 646 

Diet in, 632, 647 

Digitalis in, 634 

Diuretics in, 646 

Green soap in, 646 

Hypodermoclysis in, 633 

Injections, intravenous, in, 633 

Injections, subcutaneous, in, 633 

Inunctions in, 633 

Mercurial ointment in, 646 

Opiates in, 632 

Potash soap in, 646 

Rest in, 632, 645 

Sapo kalinus viridis in, 646 

Surgery in, 632, 645 
Perityphlitis, see Appendicitis, 634-644 
Pertussis, 73-78 

Alcohol in, 75 

Antipyrin in, 76, 77 

Belladonna in, 76 

Bromoform in, 76 

Calomel in, 75 

Cascara sagrada in, 75 

Castor oil in, 75 

Chloroform in, 75 

Climate in, 74 

Codliver oil in, 75 

Coffee in, 77 

Cresoline in, 77 

Diet in, 74 

Hygiene in, 74 

Intubation in, 75 

Iron in, 75 

Laxatives in, 75 

Prophylaxis of, 73 

Quinine in, 76, 77 

Sodium phosphate in, 75 

Strychnine in, 75 
Pharyngitis, Acute, 438-442 

Abortive treatment of, 441 

Adrenalin in, 442 

Aspirin in, 441 

Atropin in, 441 

Boric acid in, 442 

Camphor in. 441 

Chloroform in, 442 

Clothing in, 440 

Cold bathing in, 440 

Hardening in, 442 

Menthol in, 441 

Mustard foot bath in, 441 

Mustard plaster in, 441 

Opium in, 441 

Prophylaxis of, 439 

Quinine in, 441 

Zinc soziodate in, 442 
Plague, 106, 107 

Inoculations, protective, in, 18 

Injections in, 106 

Prophylactic serum in, 107 

Prophylaxis of, 106 

Sera in. 106 
Pleurisy — Exudative — Rheumatic — Tu- 
berculous, 489-498 



716 



CLINICAL INDEX 



Antipyrin in, 489 
Aspirin in, 489 
Autoserotherapy in, 494 
Caffein in, 493 
Cantharidal piaster in, 492 
Chloroform in, 491 
Digitalis in, 493 
Diuretin in, 493 
Dover's powder in, 490 
Drink restriction in, 494 
Drugs in, *o9-493 
Elaterium in, 493 
Electric baths in, 490 
Epsom salts in, 493 
Fibrolysin in, 494 
Glauber salts in, 493 
Hydrotherapy of, 490 
Iodine in, 4y2 
Jalap in, 493 
Leeches in, 491 
Leiter coil in, 491 
Menthol in, 492 
Morphine in, 492 
Priessnitz compress in, 491 
Rochelle salts in, 493 
Salicylates in, 489 
Salol in, 489 
Senna in, 493 
Sodium acetate in, 493 
Squills in, 493 
Strapping of chest, 492 
Theobromin in, 493 
Thoracentesis in, 494 
Surgery in, 497 

Pneumonia, 34, 39 
Aconite in, 42 
Adrenalin in, 48 
Ammonia in, 47 
Antipneumococcus serum in, 40 
Antipyretics in, 43 
Antitoxin of, 40 
Atropine in, 48 
Blisters in, 44 

Bloodletting, see venesection, 
Bromides in, 44 
Camphor in, 48 
Chloral in, 47 
Chlorides in, 46 
Chloroform in, 44 
Codeine in, 44 
Cupping in, 44 
Digitalis in, 47 
Dover's powder in, 44 
Epsom salts in, 38 
Expectorants in, 44 
Fomentations in, 44 
Glycerine in, 38 
Heroin in, 44 
Hygiene in, 38 
Hypodermoclysis in, 47 
Intestinal antisepsis in, 47 
Jacket in, 44 
Leeching in, 44 
Liniments in, 44 
Morphine in, 38, 44, 46, 47 
Nitroglycerine in, 42 



Oxygen in, 45 

Potassium iodide in, 42 

Prophylaxis of, 34 

Poultices in, 44 

Saline cathartics in, 46 

Salol in, 47 

Sedatives in, 44 

Sinapism in, 44 

Sodium nitrate in, 42 

Sponging in, 43 

Strapping in, 44 

Strychnine in, 47, 49 

Terpine hydrate in, 44 

Trional in, 46 

Venesection in, 42, 49 

Veratrum viride in, 42, 44 
Pseudo-Leukemia, Lymphatica, Splenica, 
Splenolymphatica, 176-179 

Arsenic in, 177 

Arsenious acid in, 177 

Cold to the spleen in, 179 

Electrization of spleen in, 179 

Eucalyptus in, 179 

Ferrum cacodylate in, 178 

Fowler's solution in, 177 

Gland extirpation in, 179 

Green soap in, 178 

Iodoform in, 178 

Iron in, 178 

Phosphorus in, 178 

Potassium iodide in, 178 

Quinine in, 178, 179 

Sodium cacodylate in, 177 

Sodium bimethyl in, 177 

Splenectomy in, 179 
Pulmonary Abscess, see Pulmonary In- 
farct 
Pulmonary Edema, 475-479 

Analeptics in, 476 

Atropine in, 477 

Bromides in, 477 

Cupping in, 477 

Drugs in, 476-478 

Ergot in, 478 

Hyoscine in, 477 

Iodides in, 477 

Leeches in, 479 

Paracentesis of the abdomen, 479 

Scopolamine in, 477 

Sodium cacodylate in, 478 

Venesection in, 479 
Pulmonary Emphysema, 471-475 

Altitude in, 473 

Analeptics in, 475 

Climate in, 473 

Diet in, 474 

Drugs in, 475 

Laxative waters in, 474 

Mineral waters in, 474 

Morphine in, 475 

Oxygen in, 475 

Pneumatic chamber in, 474 

Resorts in, 473 

Venesection in, 475 
Pulmonary Gangrene, see Pulmonary In- 
farct 



CLINICAL INDEX 



71 



Pulmonary Infarct, Abscess, Gangrene, 
479-483 
Analeptics in, 481 
Artificial respiration in, 480 
Cnloral nitrite in, 482 
Eucalyptol in. 482 
Eucalyptus in, 482 
Lavender oil in, 482 
Myrtol in, 482 
Turpentine in, 482 
Morphine in, 481 
Oxygen in, 480 
Prophylaxis of, 479 
Rest in, 480 
Surgery in, 481 
Venesection in, 481 

Pulmonary Tuberculosis, 112-137 
Acetanilid in, 131 
Alcohol in, 1x5, 120, 131, 133 
Altitude in, 117 
Alum in, 132 

Ammonium chloride in, 134 
Antipyretics in, 131 
Antpyrin in, 131 
Arsenic in, 130 
Atropine in, 133 
Balsams in, 134 
Belladonna in, 133 
Benzoin in, 133 
Calcium chloride in, 131 
Calcium hypophosphite in, 131 
Camphoric acid in, 132, 133 
Cardamoms in, 136 
Cinnamic acid in, 130 
Climate in, 116, 118 
Clothing in, 115 
Cocaine in, 136 
Codeine in, 134, 136 
Codliver oil in, 128, 130 
Copper in, 130 
Cresol in, 128 
Cresotal in, 129 

Creosote, contraindications to, 128 
Diet in, 112, 119, 135 
Dionin in, 134, 136 
Dusting powder in, 133 
Eucalyptus in, 134 
Exercise in, 118 
Forced feeding in, 119, 135 
Formaldehyde in, 132 
Fresh air in, 112 
Gentian in, 136 
Guaiacol in, 128, 129, 134 
Hardening in, 115 
Heroin in, 134 
Hill climbing in, 118 
Home treatment of, 113 
Hydrotherapy of, 132, 136 
Hypophosphite, syrup of, in, 131 
Inhalations in, 133 
Insufflations, iodoform, in, 133 
Institution treatment of, 113 
Lactic acid in, 133 
Lactophenine in, 131, 136 
Medicamentous treatment of, 120 
Menthol in, 134 



Milk in, 120, 135 

Morphine in, 134, 136 

Nuclein in, 130 

Nux vomica in, 136 

Oertel-Terrain system in, 188 

Oleoresins in, 134 

Opiates in, 133, 134 

Phenacetin in, 131 

Pyramidon in, 132 

Rectal feeding in, 135 

Rest in, 112, 118 

Salicylate in, 129 

Salicylic acid in, 133 

Seashore in, 118 

Sodium carbonate in, 130, 133 

Sodium chloride in, 133 

Specific treatment of, 120 

Sponging in, 115 

Stomachics in, 136 

Sweating in, 115 

Syrup of hypophosphite in, 131 

Talcum powder in, 133 

Tanniform in, 132 

Tent life in, 114 

Thiocol in, 129 

Tubercle bacilli in, 117 

Tubercle bacilli, emulsions of, 125 

Tubercle bacilli, watery extracts of, 125 

Tuberculin in, 120 

Tuberculin, dangers of, in, 121 

Tuberculin, therapy in, 121 

Vinegar in, 132 

Walking in, 118 

Wet packs in, 115 
Purpura, Gonorrhceica, Hemorrhagica, 

Rheumatica, Simplex, 180, 183-185 

Ergot in, 185 

Fowler's solution in, 185 

Iron chloride in, 185 

Oleum terebinthinas in, 185 

Sulphuric acid in, 185 
Putrid Bronchitis, see Bronchitis 
Pyonephrosis, see Pyelitis 
Pyelitis, Pyonephrosis, 369-373 

Argyrol in, 372 

Boric acid in, 372 

Catechu in, 370 

Copaiba in, 370 

Diet in, 370 

Juniper oil in, 370 

Lavage of renal pelvis, 371-373 

Mercury oxycyanide in, 372 

Methylene blue in, 371 

Prophylaxis of, 369 

Protargol in, 372 

Salol in, 371 

Silver nitrate in, 372 

Sodium benzoate in, 370 

Sodium sulphocarbolate in, 371 

Surgery in, 371 

Urotropin in, 370 



Rachitis, 265-270 

Calcium lacto phosphate in, 269 
Codliver oil in, 269 



718 



CLINICAL INDEX 



Diet in, 267 
Hydrotherapy of, 
Hygiene in, 266 
Lactic acid in, 267 
Lime salts in, 267 
Orthopedics in, 270 
Phosphorus in, 269 
Prophylaxis of, 266 
Rheumatism, Acute 



270 



268 
Articular, 



Chronic, 



Muscular, Pseudo-Rheumatism, 239-250 
Rheumatoid Aetheitis, Diphtheritic, in 
Gonorrhea, in Influenza, Pneumococ- 
cus, Staphylococcus, Tuberculous 

Acetanilid in, 242 

Acupuncture in, 242 

Alkalies in, 242 

Alkaline quinine treatment in, 247 

Alkaline waters in, 245 

Aspirin in, 247 

Baths in, 248 

Belladonna in, 246 

Belladonna plasters in, 243 

Beta-naphthol in, 246 

Bier's method in, 249 

Capsicum plasters in, 243 

Castor oil in, 245 

Chloroform in, 243, 246 

Clothing in, 244 

Collodion in, 246 

Diet in, 243, 244 

Douches in, 249 

Dover's powder in, 241 

Electricity in, 243, 250 

Electric baths in, 249 

Extension of limbs in, 245 

Pibrolysin in, 247 

Guaiacol in, 246 

Heat in, 243 

Hot air in, 249 

Hygiene in, 244 

Immobilization of joints in, 245 

Institution treatment in, 248 

Iodine in, 243, 246 

Iodoform, emulsions of, in, 246 

Magnesium sulphate in, 241 

Massage in, 243, 250 

Morphine in, 246 

Mud baths in, 248 

Mustard piaster in, 243 

Opiates in, 242, 243 

Orthopedic treatment in, 250 

Paracentesis of joints in, 246 

Phenacetin in, 242 

Poultices in, 243 

Prophylaxis in, 243 

Quinine in, 241 

Resort treatment in, 248 

Salicylates in, 242, 246 

Salicylic acid in, 245 

Salol in, 241, 247 

Sand baths in, 249 

Sun baths in, 249 

Thermophore in, 243 

Thiocol in, 246 

Turkish bath in, 241 

Water drinking in, 244 



Rheumatoid Aetheitis, see Rheumatism 
Rhinitis, Acute, 438-442 

Abortive treatment of, 441 

Adrenalin in, 442 

Aspirin in, 441 

Atropin in, 441 

Boric acid in, 442 

Camphor in, 441 

Chloroform in, 442 

Clothing in, 440 

Cold bathing in, 440 

Exposure to cold in, 439 

Hardening in, 440 

Menthol in, 442 

Mustard foot bath in, 441 

Mustard plaster in, 441 

Opium in, 441 

Prophylaxis of, 439 

Quinine in, 441 

Zinc soziodate in, 442 
Round Woem — Ascaris Lumbricoides, 62! 
627 

Chenopodium in, 627 

Santonin poisoning in, 627 

Spigelia in, 627 

Xanthopsia in, 627 



Scaelet Fevee, 78-82 

Ammonium acetate in, 82 

Antistreptococcus serum in, 80 

Belladonna in, 79 

Birch leaves in, 81 

Camphorated oil in, 82 

Crede ointment in, 82 

Diet in, 81 

Digitalis in, 82 

Diuretics in, 81 

Eucalyptic oil, in 79 

Formaldehyde in, 79 

Hydrotherapy of, 81 

Iron in, 82 

Isolation in, 79 

Magnesium sulphate in, 82 

Marmorek's serum in, 80 

Mercury iodide in, 79 

Prophylaxis of, 78 

Strychnine in, 82 

Urotropin in, 82 
Smallpox 

Acetanilid in, 91 

Actinic rays in, 95 

Adrenalin in, 94 

Alcohol in, 94 

Antistreptococcus serum in, 94 

Baths in, 96 

Bismuth subgallate in, 95 

Boric acid in, 95 

Brandy in, 94 

Caffein citrate in, 91 

Camphor monobromate in, 91 

Camphor phenique in, 96 

Chloral in, 91, 94 

Cocaine in, 92 

Codeine in, 91 

Cold tub bath in, 91 



CLINICAL INDEX 



719 



Diet in, 91 

Dobell's solution in, 92 
Ergot in, 94 
Formaldehyde in, 87 
Formalin in, 87 
Fuller's earth in, 93 
Glycerine in, 93 
Headache in, 91 
Ice cap in, 91 
Iron chloride in, 94 
Isolation hospital in, 87 
Liquor ammonise in, 91 
Menthol in, 94, 96 
Mercury bichloride in, 93, 96 
Morphine in, 91, 94 
Oxychlorine in, 93 
Potassium permanganate in, 96 
Prophylaxis in, 84 
Quinia in, 94 
Redlight in, 93, 95 
Revaccination in, 89 
Sodium acetatis, 91 
Sponge baths in, 91 
Strychnine in, 94 
Sunlight in, 95 
Vaccine in, 89 
Vaccination in, 19, 88 
Vaseline, carbolized in, 95 
Zinc oxide ointment in, 96 
Staphylococcus Infections, 108-109 
Autogenous vaccination in, 108 
Protective serum in, 109 
Vaccine in, 109 



Catarrhal, Erythe- 
Gangrenous, Mer- 



Stomatitis, Aphthous, 
matous, Follicular, 
curial, Ulcerative 

Atropin in, 435 

Bleeding in, 433 

Cocaine in, 434 

Chromic acid in, 435 

Glycerin in, 432 

Hydrogen peroxide in, 434 

Iodine in, 435 

Menthol in, 432 

Mouth washes in, 432 

Paquelin cautery in, 433 

Potassium chlorate in, 433, 434 

Prophylaxis of, 432 

Resorcin in, 434 

Salicylic acid in, 434 
Syphtllis, 137, 150 

Antipyrin in, 145 

Boric acid in, 137 

Carbolic acid in, 137 

Curettage in, 137 

Cypridol in, 140 

Dermatol in, 137 

Dioxy-diamino-arseno-benzol in, 146 

Europhen in, 137 

Folliculitis in, 141 

Gray oil in, 143 

Hydrarg. protoiodid in, 140 

Injection treatment in, 142 

Iodine in, 139, 144 

Iodoform in, 137 

Iodol in, 137 



Mercury in, 139 

Mercury baths in, 142 

Mercury bichloride in, 142 

Mercury ointment in, 138 

Mercury plaster in, 137, 141 

Mercury tannate in, 140 

Mixed treatment in, 145 

Nitric acid in, 137 

Opium in, 140 

Paquelin cautery in, 138 

Potassium iodide in, 145 

Resorcin in, 138 

Rubidium iodide in, 144 

Salvarsan, 146, 150 

"606," 146 

Silver nitrate in, 137 

Sodium iodide in, 144 

Tonics in, 144 

Unguentum hydrargyri in, 140 

Unguentum petrolatum in, 140 

Zinc chloride in, 137 



Taenia Mediocanellata, Taenia 
Bothriocephalus Latus, 625- 



Tape Worm 
Solium, 
626 

Aspidium felix mas in, 625 

Brayera anthelmintica in, 625 

Cusso in, 625, 626 

Granatum in, 625 

Male Fern in, 625 

Pelletierine in, 625 

Pepo in, 625 

Pomegranate in, 625, 626 

Pumpkin seed in, 625 
Tetanus, 65-69 

Antipyrin in, 69 

Antitoxin in, 65 

Cannabis indica in, 697 

Chloral hydrate in, 69 

Chloroform in, 69 

Diet in, 68 

Europhen in, 69 

Hydrotherapy of, 68 

Morphine in, 68 

Potassium bromide in, 69 

Rest in, 68 

Sodium bromide in, 69 

Tetronal in, 69 

Thiosinamin in, 69 

Trional in, 69 
Thread Worm, Anchylostomiasis, 

Corrosive sublimate in, 628 

Naphthalin in, 628 

Quassia in, 628 

Santonin in, 627 

Spigelia in, 627 

Thymol in, 628 

Vinegar in, 628 
Tonsillitis, 436-438 

Abortive treatment of, 436 

Aconite in, 437 

Alum in, 437 

Blistering in, 437 

Calomel in, 436 

Gargles in, 437 



627-628 



720 



CLINICAL INDEX 



Guaiac in, 437, 438 
Inhalations in, 438 
Iodine in, 437 
Leeching in, 437 
Leiter coil in, 437 
Magnesium sulphate in, 436 
Opium in, 437 
Potassium chlorate in, 437 
Priessnitz compress in, 437 
Sodium bicarbonate in, 438 
Sodium salicylate in, 437 
Sprays in, 438 
Surgery in, 438 
Treatment, abortive, of, 436 

Typhoid Fever, Paratyphoid, 24-34 
Acetanilid in, 26 
Adrenalin chloride in, 32 
Alcohol in, 28 
Antipyretics in, 26 
Antipyrin in, 26 
Antityphoid immune serum, 25 
Antityphoid vaccination, 25 
Arrow root in, 27 
Asafetida, milk of, in, 32 
Barley in, 27 
Bismuth subnitrate in, 32 
Boric acid in, 33 
Brand treatment in, 29 
Calomel in, 26 
Decubitus in, 33 
Diet in, 27 
Digitalis in, 32 
Endotoxins in, 24 
Gelatine in, 28 
Hydrotherapy of, 27, 28 
Ice-bag in, 32 

Intestinal antiseptics in, 25 
Lactophenin in, 26 
Liquids in, 28 
Magnesium in, 33 
Meat jelly in, 28 
Meat juice in, 27 
Meat juice, frozen, in, 28 
Milk in, 27 
Oatmeal in, 27 
Opium in, 32 
Phenacetin in, 26 
Preventive inoculations in, 25 
Prophylaxis of, 25 
Protective innoculations in, 18 
Rice in, 27 
Saline laxatives in, 33 
Salt solution in, 32 
Seidlitz powder in, 33 
Serum therapy in, 25 
Sodium sulphate in, 33 
Specific treatment of, 25 
Sponging in, 31 
Starch, enema in, 32 
Strychnine in, 32 
Styptics in, 33 
Turpentine in, 32 
Vaccine, antityphoid, in, 25 
Wine jellies in, 28 
Yeast in, 26 



U 
Ulcer of the Bowel, 597-600 

Adrenalin in, 599, 600 

Alum in, 600 

Bismuth in, 598, 600 

Boric acid in, 599 

Calcium chloride in, 599, 600 

Diet in, 598 

Ergot in, 598 

Gelatin in, 600 

Hamamelis in, 599 

Hydrastis in, 599 

Iron perchloride in, 600 

Lead acetate in, 600 

Mercury bichloride in, 599 

Opium in, 598, 599 

Salicylic acid in, 599 

Silver nitrate in, 599, 600 

Tannalbin in, 599 

Tannigen in, 599 

Thymol in, 599 
Ulcer of the Colon, 599 

Adrenalin in, 600 

Aium in, 600 

Calcium chloride in, 600 

Hemorrhage in, 600 

Silver nitrate in, 600 
Ulcer of the Rectum, 599, 600 

Adrenalin in, 600 

Alum in, 600 

Silver nitrate in, 600 
Ulcer of the Stomach, see Gastric Ulcer. 
Uremia, 383-389 

Alkalies in, 385 

Atropine in, 387 

Bile acids in, 385 

Calomel in, 385 

Cerium oxalate in, 386 

Chloral in, 389 

Chloroform in, 387, 388 

Cocaine in, 387 

Diet in, 385 

Drugs in, 385, 386 

Ether in, 388 

Hydrotherapy of, 385, 386 

Iodine in, 387 

Lavage, gastric, in, 387 

Lumbar puncture in, 389 

Mineral waters in, 385 

Opium in, 387 

Oxygen in, 388 

Prophylaxis of, 385 

Salines in, 387 

Salol in, 385 

Sodium salicylate in, 385 

Sweating in, 388 

Tannin in, 387 

Urethan in, 389 

Valerian in, 388 

Venesection in, 389 
Urethritis, Acute, Acute posterior, Chron- 
ic gonorrhoea!, Gonorrhoeal, Non-gon- 
orrhoeal, 396-430 

Bougies in, 428 

Dilation of urethra in, 419-425 



CLINICAL INDEX 



721 



Hydrastis in, 397 

Irrigation of urethra in, 413-419 

Silver nitrate in, 428 

Silver nitrate in non-infectious ure- 
thritis 429 

Valentine irrigation in, 413 

Zinc chloride in non-infectious urethritis, 
429 
Uric Acid Diathesis, Endogenous, Exogen- 
ous, 250-265 
Gout, Abarticular, Cardiac, Cerebral, Cu- 
taneous, Gastrointestinal, Retrocedent, 
Vesical, 250-265 

Alcohol in gout, 260, 265 

Antipyrin in, 265 

Aspirin in, 265 

Baths in, 261 

Blisters in, 264 

Calomel in, 264 

Camphor in, 263 

Camphor menthol in, 264 

Colchicine intoxication in, 264 

Colchicum in, 264, 265 

Colocynth pill, compound, in, 264 

Diet in, 255, 265 

Diet, Salisbury, in, 255 

Di-sodium phosphate in, 253 

Exercise in, 260 

Food nucleins in, 252 

Haustus colchici in, 264 

Heat in, 264 

Hydrotherapy of, 261 

Hyoscyamus in, 264 

Intoxication, colchicine, in, 264 

Iodine in, 265 

Massage in, 261, 264 

Mineral waters in, 259 

Mono-sodium phosphate in, 253 

Leeches in, 264 

Lithium carbonate in, 265 

Lotions in, 263 

Phenacetin in, 265 

Quinic acid in, 265 

Resort treatment of, 261 

Salisbury diet in, 255 

Seidlitz powder in, 264 

Sidonal in, 265 

Sodium urate in, 251 

Salicylates in, 265 

Urocine in, 265 



Vaginitis, Gonorrhoeal, Vulvo-Vaginitis, 
Gonorrhoeal, 409-410 

Argentonin in, 410 

Argyrol in, 410 

Ichthyol in, 410 

Protargol in, 410 

Silver nitrate in, 410 

Yeast in, 410 
Valvular Disease, Heart Disease, 273-303 

Adonas vernalis in, 287 

Aloes in, 296 

Apomorphine in, 294 

Altitude in, 280 

Ammonia in, 289 



Ammonium chloride in, 294 
Aortic incompetence, 273 
Aortic insufficiency, bromides in, 275 
Aortic insufficiency, cold in, 275 
Aortic insufficiency, cocaine in, 276 
Aortic insufficiency, heart tonics in, 274 
Aortic insufficiency, heat in, 275 
Aortic insufficiency, leiter coil in, 275 
Aortic insufficiency, opiates in, 274, 275 
Aortic insufficiency, quinine in, 275 
Aortic insufficiency, sodium bromide in, 

275 
Aortic insufficiency, valerian in, 275 
Aortic stenosis, 273 
Benzoin in, 294 
Bromides in, 290 
Caffein in, 288 
Calomel in, 296 
Camphor in, 289 
Carbonated baths in, 281 
Cascara sagrada in, 296 
Chloral in, 290 
Climate in, 280 
Compensated lesions, 274-282 
Compensated lesions, diet in, 276 
Compensated lesions, heart tonics in, 

274 
Compensated lesions, reduction of liquids 

in, 277 
Compensated lesions, water equilibrium 

in, 278 
Cupping in, 295 
Convallaria in, 287 
Decompensated lesions, 282, 290 
Decompensated lesions, cold in, 283 
Decompensated lesions, diet in, 283 
Decompensated lesions, heart tonics in, 

283 
Decompensated lesions, rest in, 282 
Diet in, 283 
Digitalin in, 284, 286 
Digitalis, chronic poisoning with, 285 
Digitalis, continued use of, 285 
Digitalis, contraindications to, 285, 286 
Digitalis, cumulative action of, 284 
Digitalis, dose of, 284 
Digitalis, glucosides, 286 
Digitalis, intoxication, 284 
Digitalis in myocarditis, 285 
Digitalis, nitrates with, 286 
Digitalis, nitroglycerin with, 286 
Digitalis, preparations of, 286 
Digitalis, tolerance and susceptibility, 

284 
Digitophyllin, 286 
Digitoxin, 286 

Drink restriction in, 277, 278 
Ergot in, 294 
Ether in, 289 
Exercise in, 278 
Fasting in, 278 
Ipecac in, 294 
Irritability in, 290 
Kissingen in, 281, 295 
Leeching in cerebral hyperemia, 292 
Leaching in heart disease, 295 
Leiter coil in aortic insufficiency, 275 



722 



CLINICAL INDEX 



279 



Marienbad in, 281, 295 
Massage in, 279 
Morphine in, 294 
Nauheim in, 279, 281 
Nitrates with digitalis in, 286 
Nitroglycerin with digitalis in, 286 
Opiates in, 290, 294 
Podophyllum in, 296 
Potassium bromide in, 291 
Poultices in, 295 
Rest in, 278, 282 
Rhubarb in, 296 
Schott treatment in, 
Sea bathing in, 281 
Sodium bromide in, 291 
Squills in, 294 
Strychnine in, 288 
Tartar emetic in, 294 
Terrain cure in, 279 
Theobromin in, 288 
Tolu, syrup of, in, 294 
Water equilibrium in compensated 
sions, 278 



Yellow Fever, 97-104 

Aconite in, 99 
Actual cautery in, 99 
Apollinaris water in, 100 
Bichloride lemonade in, 99 



le- 



Carbolic acid in, 99 
Cautery, actual, in, 99 
Cerium oxalate in, 99 
Cinchona in, 99 
Clothing in, 97 
Cocaine in, 99 
Codeine in, 99 
Creosote in, 99 
Diet in, 101 
Digitalis in, 99, 100 
Ducro's elixir in, 100 
Enemeta in, 98 
Ergot in, 99 
Foot-oath, 98 
Hydrotherapy of, 97, 99 
Hygiene in, 97, 103 
Hypoaermoclysis in, 100 
Ice-bag in, 98, 99 
Intravenous infusion in, 100 
Iron perchloride in, 99 
Lemonade, bichloride, in, 99 
Morphine in, 99 
Panopepton in, 100 
Potassium acetate in, 100 
Potassium citrate in, 100 
Prophylaxis of, 101 
Rest in, 97 
Salol in, 101 
Strychnine in, 100 
Vichy (celestin) in, 100 
White Rock Water in, 100 



SUBJECT INDEX 



Abarticular Gout, 251 
Abscess, Peritonsillar, 436 

Pulmonary, 479-483 

Tonsillar, 436 
Achylia Gastrica, 555-558 

" Gastrica in Progressive Pernici- 
ous Anemia, 152 
Acidosis and Uremia, 384 
Acne in Syphilis, 144 
Aconite Poisoning, 673 
Actinomycosis Bovis, 17 

" Hominis, 17 
Acute Articular Rheumatism, 60-66-240 

Articular Rheumatism, Myocar- 
ditis in, 304 

Bronchitis, 453-457 

Circumscribed Peritonitis, 634-644 

Endocarditis, 304-306 

Gastritis, 499-510 

Intestinal Catarrh, 573-577 

Laryngitis, 450-451 

Lead Poisoning, 689 

Nephritis, 344-350 

Rhinitis, 438-442 

Tracheo-Bronchitis, 453-457 

Urethritis, 396-403 
Addison's Disease, 340-41 
Adhesions in Cholelithiasis, 666 
Agglutinins, 19 

Albuminuria in Nephritis, 347 
Alcoholism, 673 
Alcohol Poisoning, 673 
Alum Poisoning, 674 
Amboceptors, 19 
Ammonia Poisoning, 674 
Amoebic Dysentery, 625 
Amyloid Degeneration in Pulmonary Tu- 
berculosis, 136 
Anchylostomiasis, 628 
Anemia in Gout, 262 

" Pernicious, Progressive, 151-161 

in Pulmonary Tuberculosis, 115- 
117 

Simple, 15x-161-165 

in Syphilis, 144 

Splenic, 176-179 
Aneurism of the Aorta, 312-317 
Angina Pectoris, 317-321 
Angioneurotic Edema, 476 
Anorexia in Pulmonary Tubarculosis, 135- 
136 
" in Simple Anemia, 162 
Anthrax, 17-19-109 
Antityphoid Vaccination, 25 
Antipyrin Poisoning, 675 
Antitoxins, 19 
Antimony Poisoning, 675 



Anuria and Uremia, 384 

in Nephritis, 347 
Aorta, Aneurism of the, 312-317 
Aortic Insufficiency, 247-5 

Stenosis, 273 
Aortitis Chronic, see Arterio-sclerosis, 309- 

312 
Aphthous Stomatitis, 433 
Appendiceal Abscess, 635 
Appendicitis, 634-644 
Arsenic Poisoning, 676-677 
Arterio-sclerosis, 309-312 

sclerosis, Syphilitic Disease, 312 
Arthritis, Diphtheritic, 240 

in Gonorrhea, 240 

in Influenza, 240 

Pneumococcus, 240 

Rheumatoid, 243 

Staphylococcus, 2<*0 

Tuberculous, 240 
Arthritism, 240 

Articular Rheumatism, Endocarditis, 304 
Arythmia, 325-326 
Ascaris Lumbricoides, 626 
Asthma, Bronchial, 461-466 

Catarrhal, 472 

Uremic, 388 
Athyreosis Chronica, 331 
Atonic Stages of Fever, 22 
Atropin Poisoning, 677 
Autotoxemia in Progressive Pernicious 

Anemia, 152 
Axial Rotation of the Bowel, 584 

B 

Bacillus, Colon, 110 

Pestis, 106 
Banti's Disease, 176-661 
Barium Poisoning, 678 
Bartholinitis, Gonorrheal, 407-408 
Basedow's Disease, see Graves' Disease 
Bee Stings, 678 

Belladonna Poisoning, see Atropin, 677 
Bile Passages, Diseases of the, 649-669 
Biliary Cirrhosis of the Liver, 652-661 
Black vomit in Yellow Fever, 99 
Bladder in Colon Bacillus Infections, 110 
Bleeder Families in Hemophilia, 182 
Bleeding in Chlorosis, 172 

Gums in Stomatitis, 433 
Blood, Diseases of the, 151-185 

Pressure in Epidemic Cerebro- 
spinal Meningitis, 112 
Bothriocephalus Latus, 625 

Latus, as Cause of Pernicious 
Anemia, 151 

Toxemia in Progressive Pernici- 
ous Anemia, 152 



726 



SUBJECT INDEX 



Botulism, see Food Poisoning, 687 
Brain, Passive Hyperemia of, 290 
Bright's Disease, 350-369 
Bromide Poisoning, 679 
Bromin Poisoning, 679 
Bromism, 679 
Bromoform Poisoning, 679 
Bronchi, Diseases of the, 453-470 
Bronchial Asthma, 461-466 
Bronchiectasis, 457-461 
Bronchitis, Capillary, 466 

Chronic, 457-461 
" in Arterio-sclerosis, 457 

in Chronic Nephritis, 457 
" in Emphysema, 457 

in Gout, 457 

in Heart lesions, 457 
" in Obesity, 457 

Profunda, 466 
Broncho-pneumonia, 466-470 
Buccal Cavity, Diseases of the, 431-438 
Butyric Fermentation in the Stomach, 542 



Cachexia Thyreopriva, 331 

Calorie, Definition of, 187 

Caloric Value of Carbohydrates, 188-192 

Value of Fats, 188-192 

Value of Proteids, 188-192 
Cancrum Oris, 433 
Capillary Bronchitis, 466-470 
Carbolic Acid Poisoning, 679-680 
Carbuncles in Obesity, 227 
Carcinoma of the Stomach, 533-539 
Cardiac Asthma, 461 

Dropsy, 397-303 

Edema, 297-303 
" Failure in Pneumonia, 48 
Caries, Dental, in Diabetes, 218 
Cardiospasm, 564 
Catarrh, Intestinal, Acute, 573-577 

Intestinal, Chronic, 578-583 

of Bowels in Diabetes, 220 
Case Reports in Progressive Pernicious 

Anemia, 159 
Catarrhal Asthma, 472 
" Jaundice, 649 

Stomatitis, 433 
Cavities in Pulmonary Tuberculosis, 134 
Cephalalgia in Yellow Fever, 98 
Cerebral Gout, 262 

Mycetism, 691 
Cerebro-Spinal Meningitis, Epidemic, 110- 

112 
Cheese Poisoning, see Food Poisoning, 687 
Cheyne-Stokes Breathing, 290 
Chicken-cholera, 19 
Chloral Hydrate Poisoning, 681 

" Hydrate Poisoning, Analeptics in, 
681 
Chlorin Poisoning, 682 
Chloroform Poisoning, 682 
Chlorosis, 165-172 
Cholangitis, 668-669 
Cholecystitis, 668-669 
Cholelithiasis, 661-668 

in Obesity, 227 



Cholemia, 655 
Cholera, 17-105-106 

Bacilli, 106 
Chronic Bronchitis, 457-461 

Bronchitis in Obesity, 226 

Constipation, 603-616 
" Dysentery, 72 

Gastritis, 510-522 

Inflammation of the Liver, 652- 
661 

Intestinal Catarrh, 578-583 

Lead Poisoning, 689 

Nephritis, 350-369 

Rheumatism, 239-243 
" Undernutrition in Progressive 
Pernicious Anemia, 152 
Circulatory Apparatus, Diseases of the, 273- 

326 
Cirrhosis of the Liver, 652-661 
Cocaine Poisoning, 683-684 
Colchicin Poisoning, 684 
Colic, Gall Stone, 666 
Colica Mucosa, 600 
Collapse in Ileus, 586 
Colon Bacillus, 110 

Bacillus in Cholera, 105 
Coma, Diabetic, 214-222 
Commoner Intoxications, 673-698 
Complications in Typhoid Fever, 31 

of Diabetes, 218 

of Gonorrhea, 402-403 
Composition of Food in Diseases of Meta- 
bolism, 187 
Congenital Rickets, 266 

Syphilis, 266 
Constipation, Alimentary, 604 

Atonic, 605-606 

Chronic, 603-616 

in Acute Intestinal Catarrh, 577 

in Asthma, 462 

in Chlorosis, 167 

in Diabetes, 221 

in Gout, 262 

in Ileus, 597 

in Obesity, 227 
" Physiological, 604 
" in Pulmonary Tuberculosis, 136 

Spastic, 605 

in Typhoid Fever, 33 
Coprostasis, Diarrhea in, 616 
Corrosive Sublimate Poisoning, 690-691 
Coryza in Syphilis, 144 

" Vasomotoria, 442-444 
Cough in Pneumonia, 44 

in Pulmonary Tuberculosis, 133- 
136 
Cowperitis, Gonorrheal, 406 
Cretinism, Endemic, 331 

" Sporadic, 331 
Crisis in Pneumonia, 40 
Cutaneous Gout, 263 
Cystitis, 389-396 

D 
Daily Caloric Requirement, 188 
Decompensated Lesions, 290 

Valvular Lesions, 282-290 
Delayed Resolution in Pneumonia, 49 



SUBJECT INDEX 



727 



Delirium in Pneumonia, 47 

" in Smallpox, 94 
Desiccation in Smallpox, 93-96 
Diabetes, 192 

Among Jews, 224 
" as Cause of Arterio-sclerosis, 309 

as Complication of Gout, 262 

in Children, 206 

Insipidus, 271-272 

Medium Severity of, 198 

Mellitus, 192-225 

Neurotic, 224 

Phosphaticus, 387 
Diabetic Breads, 200 
Diarrhea, 616-621 

due to Blood Borne Poisons, 618 

due to Entozoa, 617 

Dyspeptica, 617 

Gastric, 616 

in Coprostasis, 616 

in Heart Disease, 619 

in Infectious Diseases, 618 

in Influenza, 618 

in Intestinal Catarrh, 616 

in Intestinal Stenosis, 616 

in Malaria, 618 

Malarial, 573 

Nervous, 620 

in Pneumonia, 618 

in Pulmonary Tuberculosis, 136 

in Sepsis, 618 

in Typhoid Fever, 26-33 

in Uremia, 618 

Toxic, 573 

Uremic, 573 

Vaso-motoria, 621 
Digestive Apparatus, Diseases of the, 499- 
571 

Digestive Disorders in Pulmonary 
Tuberculosis, 134 
" Ferments, 520 

" Ferments in Gastric Carcinoma, 
536 
Digestibility of Foods, 503-510 
Digitalis, Chronic Poisoning with, 285 

Contraindications of, 285-286 

Intoxication, 284 

Poisoning, 685 

Preparations of, 286 

Pure Principles of, 28^-286 

Tolerance and Susceptibility, 284 
Dipntheria, 50-55 
Diplococcus, 34 
Diseases of the Bladder, 389 

of the Blood, 151-185 

of the Bronchi, 453-470 

of the Buccal Cavity, 431-438 
" of the Circulatory Apparatus, 
273-326 

of the Digestive Apparatus, 499- 
571 

of the Ductless Glands, 327-341 

Infectious, 17-150 

of the Intestines and Peritone- 
um, 573-647 

of the Liver and Bile Passages, 
649-669 



of the Lungs and Pleura, 453-498 

of Metabolism, 187-272 

of the Mouth, 432-451 

of the Nose and Throat, 438-451 

of the Pleura, 453-498 

of the Thyroid Gland, 331-334 

of the Upper Air Passages, 432- 
451 

of the Urethra, 389 

of the Urinary Apparatus, 343-430 
Distoma Hematobium as cause of Perni- 
cious Anemia, 152 
Dizziness in Aortic Insufficiency, 274 

in Pulmonary Tuberculosis, 114 
Drink Restriction in Heart Diseases, 277- 

278 
Dropsy, Cardiac, 297-303 
Ductless Glands, Diseases of the, 327-341 
Dysentery, 69-72 

Amebic, 625 
" Catarrhal, Endemic, Epidemic, 
Sporadic, Symptomatic, 69 
Dyspnea in Aneurism of Aorta, 317 

in Aortic Insufficiency, 274 

in Chlorosis, 172 

in Emphysema, 473 

E 

Eczema in Acute Attack of Gout, 264 
in Diabetes, 219 
in Obesity, 227 
" Mercuriale in Syphilis, 141 
Edema, Acute Pulmonary, 477 
" Angioneurotic, 476 
Cardiac, 297-303 
Pulmonary, 475-479 
" Pulmonary in Uremia, 387 
" in Syphilis, 144 
of Stasis, 476 
Toxic, 476 
Uremic, 387 
Ehrlich's Side-Chain Theory, 20 
Emphysema, Dyspnea in, 472 
" Obesity in, 474 

Pulmonary, 471-475 
Empyema, 497 

" in Pulmonary Tuberculosis, 117 
Endarteritis in Purpura, 184 
Endocarditis, Acute, 304-306 

" as a Complication of Pneumonia, 

304 
" in Articular Rheumatism, 304 
in Chorea, 305 
in Erysipelas, 305 
" in Gonorrhea, 305 
in Pneumonia, 304 
" in Scarlet Fever, 304 
in Syphilis, 305 
Septic, 305 
Ulcerative, 305 
Endogenous Uric Acid, 251 
Endoscope, 428 

Endotoxins in Typhoid Fever, 24 
Enteritis, Membranous, 600-603 
Enteroliths, 664 
Enteroptosis, 600-603 
Enzymes, Antitoxic, Bacteriolytic, 18 



728 



SUBJECT INDEX 



Epidemic Cerebro-spinal Meningitis, 110-112 
Epididymitis, Gonorrheal, 404 
Epigastric Pain in Aortic Insufficiency, 275 
Epistaxis, 444-449 

" and Dysmenorrhea, 445 
and Masturbation, 446 

" and Sexual Disorders, 445 

" Constitutional, 444 
in Anemia, 445 

in Diseases of the Cardio-vascular 
Apparatus, 445 

" in Hemophilia, 183-445 

" Hemorrhagic Diathesis, 445 

" in Infections, 445 

" in Intoxications, 445 

" in Leukemia, 445 

" in Purpura, 184-445 

" in Scurvy, 445 
Mechanical, 444 
Equivalent of White Bread, 200, 201 
Ergot Poisoning, 686 
Ergotism, 686 

Eruption in Smallpox, 91, 92 
Erysipelas, 108 

in Smallpox, 96 
Erythematous Stomatitis, 433 
Etherism, 687 
Ether Poisoning, 686 
Exogenous Uric Acid, 251 
Exophthalmic Goitre, 334-339 
Eyelids in Smallpox, 92 

F 
Farcy, 17 

Fat Metabolism, 192 
Fatty Degeneration of the Heart, 303, 304 

Infiltration of the Heart, 303 
Fecal Obstruction of the Bowel, 583 
Fermentative Dyspepsia, 542 
Fetor in Diabetes, 218-433 
Fever, 22-24 

in Diarrhea, 577 
" in Pulmonary Tuberculosis, 131 

Scarlet, 78, 82, 107, 108 

in Smallpox, 91-93 

Typhoid, 24-34 

Yellow, 17, 97, 104 
Fibrinous Bronchitis, 459 
Filaria, as cause of Anemia, 152 
Fish Poisoning, see Food Poisoning, 687 
Fissures in Chronic Urethritis, 428 
Flatulency, 621-624 
Floating Kidney, 381--387 
Follicular Stomatitis, 433 

Tonsillitis, 436 
Folliculitis in Syphilis, 141 
Fomentations in Pneumonia, 44 
Food Nucleins in Gout, 252 

Poisoning, 687 
" Poisoning in Acute Intesinal Ca- 
tarrh, 573 
Furunculosis in Acute Attack of Gout, 264 

in Diabetes, 216-219 
in Obesity, 227 
" in Staphylococcus Infections, 109 

G 

Galloping Consumption in Obesity, 227 



Gallstones, see Cholelithiasis, 61-668 
Gallstone Colic, 666 

" Occlusion of the Bowel, 584 
Gangrene in Diabetes, 219, 222, 223 

in Acute Attack of Gout, 264 
" in Smallpox, 96 

Pulmonary, 479-483 
Gangrenous Stomatitis, 433 
Gastralgia, 569 

in Aortic Insufficiency, 276 

in Chlorosis, 170 
Gastrectasy, 540 
Gastric Atony, 540-549 

Carcinoma, 533-539 

Diarrhea, 616 

Dilatation, 540-549 

Disorders in Chlorosis, 167 

Disturbances, in Pulmonary Tu- 
berculosis, 135 

Ectasy, 540-549 

Hyperehlorhydria, 549-555 
" Hyperesthesia, 569 
" Hypersecretion, 549-555 

Hyposecretion, 555-558 
" Neuroses, 558-571 

Ulcer, 522-533 
Gastritis, Acute, 499-510 

Chronic, 510-522 
Gastro-enterostomy, 534-549 
Gastroplication, 549 
Gastroptosis, 603 
Gastrostomy, 534 

Gingival Hemorrhage in Yellow Fever, 98 
Gingivitis, 435, 436 

in Diabetes, 218 
Gluten Bread, 200 
Glycosuria, Alimentary, 224 
Glycosuric Center, 225 
Goitre, Exophthalmic, 334-339 

Simple, 339 
Gonorrhea, Abortion of 397, 398 
Gonorrheal Urethritis, 397-403 
Gout, 250-265 

Abarticular, 251 
" Acute attack of, 265 

as a Cause of Arterio-sclerosis, 
309 

Bronchitis in, 457 

Cardiac, 263 

Retrocedent, 262 
Gouty Arthritis in Obesity, 228 

Encephalopathy, 263 
Graves, Disease, 322-334 
Gummata in Syphilis, 139 

H 
Hay Fever, 442-444 
Headache in Aortic Insufficiency, 274 

in Smallpox, 91 
Heart Failure, in Diphtheria, 51 

Fatty Degeneration of the, 303, 
304 

Neuroses of the, 317-326 

Valvular Disease of the, 273-303 
Heat Exhaustion, 699 

Fever, 699 

in Acute Attack of Gout, 264 

Prostration, 699 



SUBJECT INDEX 



729 



Hemarthrosis in Purpura, 185 
Hematemesis in Gastric Ulcer, 531 
Hematuria in Nephritis, 347 

in Nephrolithiasis, 378 
Hemophilia, 182, 183 
Hemoptysis, 483-488 

" in Pulmonary Tuberculosis, 137 
" Vicarious, 403 
Hemorrhage in Acute Yellow Atrophy of 
Liver, 184 

in Anthrax, 184 

in Cholera, 184 

in Icterus Gravis, 184 

in Intestinal Ulcer, 599, 600 
" of Lungs, see Hemoptysis 

in Pernicious Anemia, 184 

in Petechial Typhus, 184 
" in Phosphorus Poisoning, 184 

in Plague, 184 

in Ulcer of the Rectum, 600 
" in Smallpox, 184 
" in Simple Anemia, 162 

in Snake Poisoning, 184 

in Typhoid Fever, 33 

in Ulcer of the Bowel, 600 

in Ulcer of the Colon, 600 

in Urethritis, 427 

in Yellow Fever, 184 
Hemorrhagic Diathesis, 180-185 
Hemorrhoids in Obesity, 227 
Hepatic Insufficiency, 351, 352, 652, 661 
Hepatitis, Syphilitic, 214-225 
Hereditary Element in Diabetes, 223 

Element in Rachitis, 266 

Syphilis, 146 
Herpes in Diabetes, 222 
Hodgkin's Disease, 176 
Hookworm Disease, 628 
Hydrophobia, 1045 

Hyoscyamin Poisoning, see Atropin, 677 
Hyperchlorhydria, Gastric, 549-555 
Hypermotility of the Stomach, 564 
Hypersecretion, Gastric, 549-555 

Neurotic, 568 
Hypertrophic Cirrhosis, see Cirrhosis of the 

Liver, 153 
Hypochlorhydria in Progressive Pernicious 
Anemia, 153 

Neurotic, 568 
Hyposecretion, Gastric, 555-558 
Hypothetical Dangers of Antitoxin in 

Diphtheria, 51 
Hysteria as a Cause of Palpitation, 322 

as a Cause of Spastic Constipa- 
tion, 605 

in Diabetes Insipidus, 271 

I 
Icterus, 649, 652 
Ileus, 584, 596, 597 

Illuminating Gas, Poisoning from, 680 
Immunity, Active, Passive, Natural and 

Acquired, 18 
Impetigo in Smallpox, 96 
Incompetence, Aortic, 273 

Mitral, 273 

Relative, 273 

Tricuspid, 273 



Incubative Stage in Smallpox, 90 
Infarct, Pulmonary, 479-483 
Infections, Staphylococcus, 108, 109 

Streptococcus, 107, 108 
Infectious Diseases, 17-150 

Urethritis of Non-Gonorrheal 
Origin, 429, 430 
Influenza, 72, 73 

in Pseudo-Leukemia, 177 
Insomnia in Heart Disease, 290 

" in Pulmonary Tuberculosis, 114- 
136 
Insufficiency of the Cardia, 567 

of the Pylorus, 567 
Internal Secretions, 328 
Intertrigo in Obesity, 227 
Interval Operation in Appendicitis, 642 
Intestinal Catarrh, Acute, 573-577 

Catarrh, Chronic, 578-583 

Hemorrhage, 599, 600 

Hemorrhage in Purpura, 185 

Hemorrhage in Typhoid Fever, 26 

Obstruction, 635 

Parasites, 625-631 

Parasites in Leukemia, 173 
" Parasites in Purpura, 185 

Putrefaction in Pneumonia, 46 

Stenosis and Occlusion, 583-596 

Ulcer, 597-600 
Intestines, Diseases of the, 573-647 
Intoxication from Aconite, 673 

from Alcohol, 673 

from Alum, 674 

from Ammonia, 674 

from Amyl Nitrite, 675 
" from Antimony, 675 

from Antipyrin, 675 

from Arsenic, 676, 677 
" from Atropine, 677 

from Barium, 678 

from Bee Stings, 678 

from Belladonna, 677 

from Botulism, 687 

from Bromide, 679 

from Bromin, 679 

from Bromoform, 679 

from Calcium, 679 

from Carbolic Acid, 679, 680 

from Carbon Dioxide, 680 

from Carbon Monoxide, 680 
" from Cheese Poisoning, 687 

from Chloral Hydrate, 681 

from Chlorate of Potash, 681 

from Chlorin, 682 

from Chloroform, 682 

from Cocaine, 683, 684 

from Colchicin, 684 

from Colchicin in Gout, 264 

from Corrosive Sublimate, 690, 
691 

from Digitalis, 685 

from Ergot, 686 

from Ether, 686 

from Fish, 687 

from Food, 687 

from Heat Prostration, 699 

from Hydrochloric Acid, 682 



730 



SUBJECT INDEX 



" from Hydrocyanic Acid, 695 

from Hyoscyamin, 677 
" from Illuminating Gas, 680 
from Iodides, 687, 688 
from Iodine, 687 
from Iodoform, 688 
from Lead, 689 
from Lrime Salts, 679 
from Mercury, 690, 691 
from Morphine, 692 
from Mushrooms, 691 
" from Nitroglycerin, 692 
" from Nux Vomica, 698 
from Opium, 692 
from Oxalic Acid, 693 
from Oysters, 687 
" from Phosphorus, 694 
from Pilocarpin, 695 
from Prussic Acid, 695 
" from Quinine, 695 
from Salicylates, 696 
from Salicylic Acid, 696 
from Silver, 696 
from Silver Salts, 696 
from Snake Bite, 697 
" from Strophanthus, 685 
from Strychnia, 698 
from Sun Stroke, 699, 700 
Intussusception of the Bowels, 584 
Iodides, Poisoning from, 687, 688 
Iodine Acne, 688 

Poisoning, 687 
Iodoform Poisoning, 688 
Irritability in Aortic Insufficiency, 274 

in Heart Disease, 290 
Ischemia of the Brain in Aortic Insuffi- 
ciency, 274 
Itching in Icterus, 652 
" in Smallpox, 93 



Jaundice, Catarrhal, 649 

in Yellow Fever, 97 



K 



Knotting of the Bowel, 584 



Lacunar Tonsillitis, 436 
Laryngitis, Acute, 450, 451 
Law of I so dynamics, 188 
Laws of Nutrition, 187-192 
Lead Poisoning, 689 
Leptothrix in Pruritus, 219 
Leucocytes, in Appendicitis, 637 
Leukemia, 172-176 

Leucocytic, 173 

Lymphocytic, 173 

Myelogenous, 173 

Splenic, 173 
Lithemia, 251 
Liver, Chronic Inflammation of the, 652-661 

Diseases of the, 649,669 
Lungs, Diseases of the, 453-498 
Lymphadenomata, 176 



M 

Malaria, 55-60 

" as Cause of Pernicious Anemia, 

152 
" in Pseudo-Leukemia, 177 
Malarial Epididymitis, 405 

Spleen, 179 
" Spleen in Pseudo-Leukemia, 179 
Malignant Pustule, 109 

Syphilis, 145 
Masturbation and Epistaxis, 446 
Measles, 83, 84 

in Pseudo-Leukemia, 177 
Megalogastria, 540 
Membranous Enteritis, 600-603 
Mercurialism, 690 
Mercurial Stomatitis, 433, 434 
Mercury Poisoning, 690, 691 
Metabolism, Diseases of, 187-272 
Meteorism, 621-624 

in Ileus, 595 
" in Pulmonary Tuberculosis, 136 
" in Typhoid Fever, 32 
Morbus Maculosus, 183 
Morphine Poisoning, 692 
Morphinism, 693 

Mosquito in Yellow Fever, 101-103 
Motor Insufficiency of the Stomach, 540, 

549, 564, 568 
Mouth, Diseases of the, 432-451 
Mucous Colic, 600-603 
Multiple Hemorrhages in Purpura, 184 

Sarcomatosis, 176 
Muscular Rheumatism, 241 
Mushroom Poisoning, 691 
Mycetism, 691 

Mycosis Vulvae in Pruritus, 219 
Myocarditis, 303, 304 

Acute, 304 

Chronic, 304 
" in Acute Articular Rheumatism, 
304 

Types of, 303 
Myxedema, 331-334 

Fetal, 331 

Infantile, 331 
Myxedematous Idiotism, 331 

N 

Nausea in Appendicitis, 640 

in Perityphlitis, 640 
Necrosis in Gout, 254 
Nephritis, 343-369 

Acute, 344-350 

Chronic, 350-369 

in Acute Articular Rheumatism, 
62 
" in Diphtheria, 51 

in Parotitis, 78 

in Scarlet Fever, 82 
" in Smallpox, 94 
- " Vascular, 343 

in Yellow Fever, 97 
Nephrolithiasis, 373-387 

Oxaluric, 380 

Phosphatic, 380 

Urica, 374-379 



SUBJECT INDEX 



731 



Nephorrhaphy, 383 
Nervous Diarrhea, 620 

Dyspepsia, 570 
Neuralgia in Diabetes, 222 
Neurasthenia as a Cause of Palpitation, 322 

as a Cause of Spastic Constipa- 
tion, 605 

in Aortic Insufficiency, 274 
Neurasthenic Types of Diabetes, 212 
Neuritis, Diabetic, 222 

in Syphilis, 144 
Neurosal Element in Chlorosis, 166 
Neuroses of the Heart, 317-326 

of the Stomach, 558-571 
Neurotic Diabetes, 224 
Noma, 433, 434 
Nose Bleed, see Epistaxis, 444 
" Diseases of the, 438-451 



Obesity, 225-238 

as a Cause of Arterio-sclerosis, 309 
" as a Complication of Gout, 262 
Three Degrees of, 228 
Occlusion, Intestinal, 583-596 
Oidium Albicans, 433 
Onychia in Syphilis, 139 
Opsonic Index in Pulmonary Tuberculosis, 
121 
Index in Staphylococcus Infec- 
tions, 109 
Index in Typhoid Fever, 25 
Osteomalacia, 270, 271 
Otitis in Scarlet Fever, 82 
Ottawa Tent Colony in Pulmonary Tuber- 
culosis, 122 
Oxyuria Vermicularis, 627 
Oyster Poisoning, see Food Poisoning, 687 



Pain in Intoxications, 672 

" in Pneumonia, 43 
Palpitation, 321-325 

in Chlorosis, 172 

in Nephritis, 322 
Pancreatitis, Syphilitic, 214-225 
Paralysis in Diphtheria, 51 
Parasites, Intestinal, 625-631 
Parenchymatous Tonsillitis, 436 
Parotitis, 78 

Peliosis Rheumatica, 183 
Pemphigus in Diabetes, 222 
Pericarditis, 306-308 

in Pneumonia, 49 
Pericardiac Pseudo Cirrhosis of the Liver, 

661 
Perforating Ulcer in Diabetes, 222 
Peristaltic Unrest, 564 
Peritoneum, Diseases of the, 573-647 
Peritonitis, Acute Circumscribed, 634-644 

Acute Diffuse, 631-634 

Acute Perforative, 635 

in Pneumonia, 49 
Peritonsillar Abscess, 436 
Pernicious Anemia, Progressive, 151-161 
Pertussis, 73-7S 
Perityphlitis, 634-644 
Perityphlitic Abscess, 635 



Pharyngitis, Acute, 438-442 
Phlebitis, 480 
Phosphorus Poisoning, 694 
Pilocarpin Poisoning, 695 
Plague, 160, 107 
Plethora in Epistaxis, 449 
Pleura, Diseases of the, 453-498 
Pleurisy, Exudative, 493 
Rheumatic, 489 

in Pulmonary Tuberculosis, 117 
" Tuberculous, 489 
Pleuritis, see Pleurisy, 489-498 
Pneumatosis of the Stomach, 566 
Pneumonia, 34-50 

in Obesity, 227 
Pneumothorax, 497 

" in Pulmonary Tuberculosis, 117 
Poisoning from Aconite, 673 
from Alcohol, 673 
" from Alum, 674 
" from Ammonia, 674 
" from Amyl Nitrite, 675 

from Antimony, 675 
" from Antipyrin, 675 

from Arsenic, 676, 677 
" from Atropine, 677 
" from Barium, 678 

from Bee Stings, 678 
" from Belladonna, 677 

from Bromide, 679 
" from Bromin, 679 

from Bromoform, 679 
from Calcium, 679 
from Carbolic Acid, 679, 680 
" from Carbon Dioxide, 680 
from Monoxide, 680 
from Cheese, 687 
from Chloral Hydrate, 681 
from Chlorate of Potash, 681 
from Chlorin, 682 
from Chloroform, 682 
from Cocaine, 683, 684 
from Colchicin, 684 
from Corrosive Sublimate, 690, 

691 
from Digitalis, 685 
from Ergot, 686 
from Ether, 686 
from Fish, 687 
from Food, 687 
from Hydrochloric Acid, 682 
from Hydrocyanic Acid, 695 
from Hyoscyamin, 677 
from Illuminating Gas, 680 
from Iodides, 687, 688 
from Iodine, 687 
from Iodoform, 688 
from Lead, 689 
from Lime Salts, 679 
from Mercury, 690, 691 
from Morphine, 692 
" from Mushrooms, 691 

from Nitroglycerin, 692 
" from Nux Vomica, 698 
from Opium, 692 
from Oysters, 687 
" from Phosphorus, 694 
from Pilocarpin, 695 



732 



SUBJECT INDEX 



from Prussic Acid, 695 
" from Quinine, 695 
" from Salicylates, 696 

from Salicylic Acid, 696 

from Silver, 696 

from Silver Salts, 696 

from Snake Bite, 697 

from Strophanthus, 685 

from Strychnia, 698 
Pollen as a Cause of Hay Fever, 442 
Polyuria, Hysterical, 271 

Symptomatic, 271 
Primary Progressive Anemia, 151 
Progressive Pernicious Anemia, 151-161 
Prostatitis, Gonorrheal, 403 
Proteid Metabolism, 192 
Pruritus in Diabetes, 219 
Prussic Acid Poisoning, 695 
Pseudo-anginal Paroxysms, 321 

Arthritis Vertebralis, 239 

Hay Fever, 442 

Leukemia, 176-180 
" Leukemia Splenica, 176 
" Leukemia Lymphatica, 176 

Leukemia Splenolymphatica, 176 

Rheumatism, 240 
Ptomaines in Food Poisoning, 687 
Ptyalism, 433 
Pulmonary Abscess, 479-483 

Edema, 475-479 

Emphysema, 471-475 

Gangrene, 479-483 

Infarct, 479-483 

Stenosis, 273 

Tuberculosis, 112-137 
Purpura, 180, 183, 185 

Gonorrheica, 184 
" Hemorrhagica, 183 

Rheumatica, 183 

Simplex, 183 
Putrid Bronchitis, 458 
Pyelitis, 369-373 
Pyloroplasty, 549 
Pyloric Insufficiency, 567 
Pylorospasm, 565 
Pyonephrosis, 369-373 
Pyorrhea in Diabetes, 218 

Q 

Quinine Poisoning, 695 

R 

Rachitis, 265-270 
Rattlesnake Venom, 19 
Recurrent Fever, 17 

Glandular Fever, 176 
Red Gum in Pulmonary Tuberculosis, 134 
Regular Articular Paroxysm in Gout, 263 
Regurgitation of Food, 567 
Relative Incompetence, 273 
Remissions in Progressive Pernicious 

Anemia, 159 
Renal Asthma, 461 
Resection of Pylorus, 534 
Retrocedent Gout, 262 
Rheumatic Arthritis in Obesity, 228 

Fever, 60, 66, 108, 240 

Pleurisy, 489 



Rheumatism, 239-250 

Acute Articular, 60, 66, 240 

Chronic, 239-243 

Muscular, 241 
Rheumatoid Arthritis, 243-250 
Rhinitis, Acute, 438-442 
Rickets and Syphilis, 266 

Congenital, 266 
Round-worm, 626 
Rumination, 567 



Salicylate Poisoning, 696 

Salicylic Acid Poisoning, 696 

Santonin Poisoning, 627 

Scarlatina in Rheumatism, 240 

Scarlet Fever, 72, 82, 107, 108 

Schonlein's Disease, 183 

Scrofula in Pseudo-leukemia, 176 

Scurvy, 180-182 

Seasickness, 566, 567 

Secondary Anemia, see Simple Anemia 

Secretory Neuroses of the Stomach, 568 

Sensory Neuroses of the Stomach, 569 

Serpiginous Syphilide, 145 

Sepsis, Diarrhea in, 618 

Septicemia in Colon Bacillus Infections, 

110 
Sequelae of Diabetes, 218 
Silver Poisoning, 696 
Simple Anemia, 151, 161, 165 

Anemia, Causes of, 161 

Goitre, 339 
Smallpox, 17, 84, 97 
Snake Poisoning, 697 
Somnolence in Heart Disease, 290 
Spastic Constipation, 605 
Spinal Arthropathies, 239 
Splenic Anemia in Pseudo-leukemia, 179 

Tumor in Malaria, 59 
Staphylococcus Infections, 108, 109 

in Tetanus, 65 
Stasis due to Decompensated Heart Le- 
sions, 290 
Steatorrhea in Diabetes, 215-221 
Stegomyia Fasciata in Yellow Fever, 101 
Stenosis, Aortic, 273 

Intestinal, 583-596 

Mitral, 273 

Pulmonary, 273 

Tricuspid, 273 
Stercoral Typhlitis, as a Cause of Appendi- 
citis, 641 
Sthenic Periodic Fever, 22 
Stomach, Carcinoma of the, 533-539 

Motor Insufficiency of the, 540, 
549, 564, 568 
Stomatitis, 431-435 

Aphthous, 433 

as a Complication of Anemia, 431 

as a Complication of Cachexia, 
431 

as a Complication of Diabetes, 431 
" as a Complication of Hepatic Dis- 
orders, 431 

as a Complication of Infectious 
Diseases, 431 



SUBJECT INDEX 



733 



" as a Complication of Intestinal 
Disorders, 431 
Catarrhal, 433 
Erythematous, 433 
Follicular, 433 
Gangrenous, 433 
in Acetonemia, 431 
in Diabetes, 218 
" in the Hemorrhagic Diathesis, 432 
in Syphilis, 144 
in Typhoid Fever, 26 
" in the Uric Acid Diathesis, 431 
Mercurial, 433, 434 
Thrush, 433 
Ulcerative, 433 
Strangulation of the Bowel, 584 
Streptococcus Infections, 107, 108 
Strophanthus Poisoning, 685 
Strychnia Poisoning, 698 
Sun Stroke, 699 

Suppurating Glands in Syphilis, 138 
Swine Plague, 19 
Syphilis, 17, 137, 150 

" as a Complication of Endocardi- 
tis, 305 
" as a Cause of Arterio-sclerosis, 

309 
" as a Cause of Leukemia, 173 
" as .Cause of Pernicious Anemia, 

152 
" in Diabetes, 225 
in Leukemia, 173 
of the Liver, 652-661 
" Malignant, 145 
Syphilitic Hepatitis, 214-225 
Pancreatitis, 214-225 



Taenia Mediocanellata, 625 
Solium, 625 

Tape-Worm, 625, 626 

Tenesmus in Cystitis, 294 

Tetanus, 65-69 

Bacillus, 65 

The Commoner Intoxications, 671-698 
" Anemias, 151 

Thread Worm, 627 

Throat, Diseases of the, 438-451 

Thrush Stomatitis, 433 

Thyroidectomized Animals, 335 

Thyroidectomy, 338 

Thyroidism, 333 

Tonsillar Abscess, 436 

Tonsillitis, 436-438 

Follicular, 436 
" Lacumar, 436 
" Parenchymatous, 436 

Tophi in Gout, 262 

Toxic Edema, 476 

Erythema in Syphilis, 141-144 

Tracheo-Bronchitis, Acute, 453-457 



Tricuspid Incompetence, 273 

Stenosis, 273 
Trophic Disorders in Diabetes, 222 
Tubercle Bacilli, 117 
Tuberculosis in Diabetes, 221 

in Obesity, 227 
" in Pseudo-Lukemia, 177 

of the Peritoneum, 645-647 

Pulmonary, 112-137 
Tuberculous Adenitis, 176 

Peritonitis, 645-647 

Pleurisy, 487 
Tumor in Appendicitis, 637 
Typhoid Fever, 24-34 

U 

Ulcer, Gastric, 522-533 

Intestinal, 597-600 

of the Bowel, 697-600 

of the Colon, 599 

of the Rectum, 599 
Ulcerative Stomatitis, 433 
Uncinariasis, 628 

Upper Air Passages, Diseases of the 432-451 
Uremia, 383-389 

" in Hepatic Cirrhosis, 656 
Uremic Asthma, 461 
Urethral Fever, 425 
Urethritis, Acute, 396-403 

" Acute Posterior, 402 

" Chronic Gonorrheal, 411-430 

Gonorrheal, 397-403 

Non-gonorrheal, 429, 430 
Uric Acid Diathesis, 250-265 
Urichemia, 251 
Urinary Apparatus, Diseases of the, 343- 

430 
Urinemia and Uremia, 384 
Urticaria in Diphtheria, 51 



Vaginitis, Gonorrheal, 409, 410 
Valvular Disease, 273-303 
Vascular Nephritis, 343 
Venereal Papilloma in Syphilis, 138 

Ulcer in Syphilis, 137 
Venous Stasis as a Cause of Epistaxis, 448 
Vesical Gout, 263 
Vicarious Menstruation, 446 
Volvulus of the Bowel, 584 
Vomiting in Appendicitis, 640 

in Diabetes, 220 

in Uremia, 386 

Nervous, 566 
Vulvo-vaginitis, Gonorrheal, 409-410 

W 
Wasserman Reaction, 149 
Whooping-cough in Pseudo-leukemia, 177 

Y 

Yello.v Fever, 17, 97, 104 



JAM 8 1912 






One copy del. to Cat. Div. 



JAN e 



